Antenatal care (ANC) and postnatal care (PNC) are critical opportunities for women, babies and parents/families to receive quality care and support from health services. Community-based interventions may improve the accessibility, availability, and acceptance of this vital care. For example, community mobilization strategies have been used to involve and collaborate with women, families and communities to improve maternal and newborn health.To synthesize existing reviews of evidence on community mobilization strategies that strengthen support for appropriate and timely use of ANC and PNC.Six databases  were searched for published reviews that describe community mobilization related strategies for ANC and/or PNC. Reviews were eligible for inclusion if they described any initiatives or strategies targeting the promotion of ANC and/or PNC uptake that included an element of community mobilization in a low- or middle-income country (LMIC), published after 2000. Included reviews were critically appraised according to the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Evidence Syntheses. This review of reviews was conducted following JBI guidelines for undertaking and reporting umbrella reviews.In total 23 papers, representing 22 reviews were included. While all 22 reviews contained some description of community mobilization and ANC/PNC, 13 presented more in-depth details on the community mobilization processes and relevant outcomes. Seventeen reviews focused on ANC, four considered both ANC and PNC, and only one focused on PNC. Overall, 16 reviews reported at least one positive association between community mobilization activities and ANC/PNC uptake, while five reviews presented primary studies with no statistically significant change in ANC uptake and one included a primary study with a decrease in use of antenatal facilities. The community mobilization activities described by the reviews ranged from informative, passive communication to more active, participatory approaches that included engaging individuals or consulting local leaders and community members to develop priorities and action plans.While there is considerable momentum around incorporating community mobilization activities in maternal and newborn health programs, such as improving community support for the uptake of ANC and PNC, there is limited evidence on the processes used. Furthermore, the spectrum of terminology and variation in definitions should be harmonized to guide the implementation and evaluation efforts. Antenatal care (ANC) and postnatal care (PNC) are critical opportunities for women, babies, parents/caregivers and families to receive quality care. A global study on ANC found significant interregional and intercountry inequalities in ANC service utilization, especially in Asia and Africa . In 20162 as well as increase acceptability and accessibility to the interventions [ANC and PNC share several common factors that may affect their uptake and utilization, including providers’ skills, the relationship between health workers and women, local infrastructure such as distance and transportation to facilities, as well as the influence of women and families’ knowledge, attitudes, beliefs and culture norms regarding care -12. As sventions .While the definition of community mobilization varies in the literature, it can largely be described as involving community members in activities to increase support and actions for an intended cause ,15. TherHowever, there is also a need to consider the full spectrum of community mobilization activities and implementation processes, and how they improve community support for ANC/PNC. Specifically, the purpose of this review of reviews is therefore to synthesize the existing evidence on what community mobilization strategies are effective in increasing family and community support for appropriate and timely use of ANC and PNC in LMICs. Within these community mobilization strategies, the review also seeks to understand what strategies are used to strengthen family and community support for use of ANC in the first trimester of pregnancy. The findings of this review of reviews are then applied to the 2019 logic model pathway for uptake of ANC services described by Downe et al, which underpins the WHO recommendations on ANC .A systematic review of reviews was conducted in order to gather existing evidence on community mobilization strategies that strengthen support for appropriate and timely use of ANC/PNC, including use of ANC in the first trimester of pregnancy. This approach summarizes the findings of published reviews to synthesize existing evidence in an overview that can inform future guidelines, programmes, and policy -30. As tStudies were eligible for inclusion if they described any interventions, initiatives or strategies targeting the promotion of ANC and/or PNC uptake that included an element of community mobilization in a low-and middle-income country (LMIC), as defined by the World Bank Classification at time of study. Eligible reviews of published literature included, but were not limited to, literature reviews, narrative reviews, realist reviews, systematic reviews, scoping reviews, and qualitative evidence syntheses. Only studies published on or after 2000 were included. This year was chosen as a cut-off point in order to capture more relevant research, aligning with the Millennium Development Goals and increased attention on ANC/PNC for maternal, newborn and child health and with the growing focus on community-based interventions such as community mobilization. The search strategy was designed around three main concepts: community mobilization, ANC/PNC, and reviews  independently screened the resulting studies’ titles and abstracts. After discussing any conflicts, the reviewers analyzed full texts to determine final inclusion data set, again discussing any conflicts. A third reviewer (AGP) reviewed 20% of the included and excluded articles at full-text stage.One reviewer (SD) extracted data from all included studies into an Excel sheet using a pre-developed data extraction tool. Review characteristics and findings relevant to community mobilization and ANC/PNC uptake were considered. Extracted data included: number of studies and geographic range, participants, specific community mobilization strategies used, barriers and facilitators to activity implementation, outcomes reported in the review, recommendations by the review authors, etc. A second reviewer (BG) independently extracted data on approximately 20% of included reviews to compare for inter-rater reliability and resolve any potential discrepancies and also examined all other extracted data for consistency. Data was extracted as it was presented in the published reviews. Reviewers did not extract from the primary sources that were referenced. This led to varying levels of detail in the major findings of reviews as some reported specific outcomes of primary studies while others did not.Two reviewers  assessed the quality of the included reviews using the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Syntheses ,33. ThisFindings from the data extraction were synthesized to answer the research questions previously presented. This was done by collecting the overall conclusions on community mobilization and reported outcomes for ANC and/or PNC utilization, listing the range of mentioned community mobilization strategies and activities used within MNH programmes, and grouping reviews that included community mobilization that impacted on early ANC uptake. In addition to presenting evidence from the included reviews, this review used findings from a recent qualitative evidence synthesis on routine ANC uptake to contextualize some of the practical implications for community mobilization . Downe eSearching occurred between 28 January and 15 February 2021. An updated database search was conducted on 2 September 2021. As highlighted in . No reviews were excluded based on quality, however the challenges reviews faced in terms of quality centered around appropriate and validated appraisal processes as well as clear strategies and sources. Additionally, it is important to note that while all reviews presented included some description of community mobilization and ANC/PNC, 12 articles presented more in-depth details on the community mobilization processes and outcomes relevant to this review of reviews [The JBI Critical Appraisal tool was applied to all included studies and the assessments are available in Appendix S2 in the  reviews -49,51,53The 22 reviews ranged in size and scope. Most reviews focused broadly on RMNCH -51,53,54Overall, reviews describe a positive association between community mobilization and ANC/PNC uptake. The ANC/PNC utilization outcomes documented by the reviews varied, perhaps explaining the dearth of meta-analyses conducted. Reviews described specific outcomes such as number of antenatal examinations , utiliziWhile it was not possible to synthesize results in meta-analyses due to high heterogeneity across included studies, 15 reviews reported at least one positive association between what they described as community mobilization activities and ANC and/or PNC uptake ,51,53,54The varying levels of detail presented in the reviews presented challenges in synthesizing findings across all reviews. The 12 reviews (13 papers) that described community mobilization and ANC/PNC in greater depth comprise the main focus for the rest of this publication. As demonstrated in Additionally, there are various definitions and levels of community mobilization; and an array of activities that are called community mobilization. This review of reviews highlights that heterogeneity as well. Strategies and activities described by the reviews ranged from passive communication to more active approaches that included involving community members or consulting local leaders. P < 0.001) [Three reviews included one study each that identified early use of ANC as an outcome. The findings and strategies presented by the relevant primary studies are summarized below. George et al. described a study using discussions and participatory exercises in women’s groups to develop a monitoring tool for maternal health care . The too< 0.001) .A recent qualitative evidence synthesis on uptake of routine ANC, conducted to inform the development of WHO’s ANC recommendations, identified 52 factors  across three overarching domains  that influenced the initial or continued use of ANC . AppendiBehavioral beliefs may be influenced by the information and knowledge individuals have. Community mobilization strategies that focus on information, education, communication, and awareness can influence these initial behavioral beliefs by providing additional information. However, reviews also highlight the importance of incorporating local knowledge and tradition into these methods and communication materials ,45. NormThe objective of this review of reviews was to identify community mobilization strategies used to support appropriate and timely use of ANC (including early access in the first trimester) and PNC in LMICs. This review of reviews identified 23 publications representing 22 reviews that described using community mobilization to influence ANC/PNC uptake. The reviews ranged in their methods, objectives, and descriptions of community mobilization strategies as well as their definitions of early ANC (12 vs 16 weeks). Overall, the majority of studies noted the importance of community mobilization in delivering or improving support for ANC/PNC uptake either as a main intervention or within a package of interventions. However, reviews largely focused on the statistical outcomes of including a “community mobilization component” such as changes in uptake of services or mortality rates. While many of these reviews stated or implied an element of community mobilization was present, they often did not describe in sufficient detail what this process entailed or how it was implemented . As a reThe logic model presented by the Downe et al. qualitative evidence synthesis and adapted in This involvement of community members can extend to the inclusion of women and families through participatory activities and peer groups that are implemented in ways that respect societal norms. A methodology described by multiple reviews is the Warmi methodology, first introduced by Save the Children in Bolivia in 1990 . This muThese findings have implications for practice, policy, and research. As established in the literature, a range of factors influence the utilization of appropriate and timely ANC/PNC ,27,67-69Notably, barriers and facilitators are different across contexts making these programs a complex health intervention which could benefit from being considered through an implementation science or complexity science lens . ImplemeBy analyzing literature at the review level, this paper provides a comprehensive overview of the existing evidence and highlights implications for policy and practice as well as research gaps. Notably, this review of reviews emphasizes how the current descriptions of incorporating these community mobilization activities are often limited in detail or a brief sentence in a publication’s methodology section. There is a need to document and learn from the processes of community mobilization strategies when they are implemented, often within larger MNH packages. However, in order to do this and guide eventual implementation this review of reviews also calls for programmers and researchers to clearly define and explain the strategies and processes used to mobilize a community. The high heterogeneity of review designs made it challenging to synthesize findings across a varied range of interventions and outcomes. This heterogeneity comes from the variety of review objectives, activities, and reported metrics and outcomes. The included reviews presented varying levels of detail in their findings – some reviews reported specific study results, while others alluded to groups of studies more generally. Additionally, as this is a review of reviews, some primary studies were represented in multiple reviews which may have emphasized or over-represented some individual studies’ findings. Finally, ANC and PNC were often not the main focus of the reviews. Many reviews considered sexual and reproductive or maternal, newborn, and child health more broadly with ANC/PNC as one component or outcome. As a result, increasing community support for ANC/PNC specifically was often not the main focus of the interventions and strategies they described. This implies community mobilization activities described in this review cannot be simply extrapolated to improve ANC/PNC uptake, but they will need to be part of broader MNH programme strategy as demonstrated by many of the included studies ,18.Since the Alma Ata Declaration that prioritized community participation in health care, programs and policies that include community members in all aspects of health care have been widely advocated for within MNH . CommuniCommunity-based interventions, and particularly community mobilization approaches are emphasized in MNH programmes throughout different global strategies. Yet, this review affirms that there is little consistency in what this means, how it is implemented and poor documentation that allows us to understand and appreciate what has been done and what was the effect . As note


In “Toward Designs of Workplace Stress Management Mobile Apps for Frontline Health Workers During the COVID-19 Pandemic and Beyond: Mixed Methods Qualitative Study” :e30640) the authors noted one error.In the originally published manuscript, the title was incorrectly set as:Toward Designs of Workplace Stress Management Mobile Apps for Frontline Health Workers During the COVID-19 Pandemic and Beyond: Design Implications for a Mixed Methods Qualitative StudyThe title has been corrected to:Toward Designs of Workplace Stress Management Mobile Apps for Frontline Health Workers During the COVID-19 Pandemic and Beyond: Mixed Methods Qualitative StudyThe correction will appear in the online version of the paper on the JMIR Publications website on January 25, 2022, together with the publication of this correction notice. Because this was made after submission to PubMed, PubMed Central, and other full-text repositories, the corrected article has also been resubmitted to those repositories.


The coronavirus disease 2019 (COVID-19) pandemic is deeply affecting people’s mental health. Estimates indicate the pandemic has led to at least a 25% increase in the prevalence of common conditions such as depression and anxiety disorders, with women and young people most affected.Mental health was a largely unaddressed challenge before the pandemic. Mental health conditions are among the leading causes of disability worldwide, with a cumulative global loss of economic output estimated to exceed 16 trillion United States dollars between 2011 and 2030.The COVID-19 pandemic has exposed the consequences and limitations of underinvestment in mental health services. In a World Health Organization (WHO) survey on the impact of the pandemic on essential health services, only 17% (20/116) of WHO Member States who reported integrating mental health and psychosocial support within their COVID-19 response plans also reported allocating full funding to these components.,Emergencies that exacerbate mental health challenges – such as the COVID-19 pandemic – can and do bring renewed attention to the mental health and well-being of those affected.WHO, the World Bank, Member States and partners have responded to the mental health and social needs brought about by the pandemic. WHO and Inter-Agency Standing Committee partners have provided technical support and guidance to countries in developing and coordinating effective mental health and psychosocial responses to the pandemic and have developed widely translated and adapted resources.Despite these efforts, more needs to be done to transform initial attention into sustained action. To ensure such comprehensive transition, we suggest putting forward three key actions. First, the global health and development community must identify mental health as a cross-cutting priority for humanitarian, peacebuilding and development actors, both in terms of sustainable recovery from the COVID-19 pandemic and of sustainable development. Mental health needs are often only recognized in the short-term, yet the mental health consequences of exposure to severe stress are long-term.Second, we must reformulate health financing policies and essential packages of care, in line with the principles of universal health coverage and available evidence. Mental health conditions are rarely given a level of priority or resourcing that is proportionate to their public health and socioeconomic effects. Many of the tools and strategies necessary to build robust, integrated and resilient mental health systems are well establishedThird, we must progressively integrate mental health into health system strengthening efforts and existing financing instruments for health improvement and social development. Many innovations for delivering mental health interventions at community, primary health care and clinical care levels exist, providing practical solutions to constraints such as stigma and lack of a well-trained workforce. Such integration will require support from the existing financing instruments. Mental health can also be prioritized through mechanisms such as the World Bank’s health sector financing. Recently established mechanisms, notably the Multi-Partner Trust Fund to Catalyse Country Action for Noncommunicable Diseases and Mental Health, can generate domestic development, financing and advancement of mental health systems through cost-effective investment in proven approaches. The Global Financing Facility for Women, Children and Adolescents could also play an important role in supporting these population groups.Only with consolidated action can mental health become a sustainable development priority.


Actionable policy-relevant research is critical to improving population health and advancing health equity, as research provides an evidence base for the development of effective policies and programs. For academic researchers with an interest in addressing the upstream social and structural causes of health inequities, conducting this type of research remains a challenge. To maximize the utility of research findings, academic researchers need to collaborate with researchers with applied public health experience, including government and other stakeholders, but may not have the time and knowledge needed to navigate complex government bureaucracy. To influence policy and program development, academic researchers also must understand the broader, applied context, along with the skills needed to communicate relevant findings to decision-makers.While large city health departments collect vast amounts of data and make efforts to expand access to those data, there remain real and perceived barriers to the effective and efficient use of these data for maximum policy and programmatic impact , 2. ApplThere are an array of initiatives that aim to promote multi-institutional, multi-sectoral collaboration; expand access to available population health data; or provide mentorship for early- and mid-career academic researchers , 4. We hJournal of Urban Health, we describe the development of Health Data for New York City (HD4NYC), which aims to advance policy-relevant, health equity-focused research by combining multi-institutional and interdisciplinary collaboration, access to data, and mentorship. We also describe select initial research products emerging from this new, unique program.In this issue of the HD4NYC was launched by the New York Academy of Medicine (NYAM) and the New York City Department of Health and Mental Hygiene  in March 2019, with funding from the Robert Wood Johnson Foundation. HD4NYC builds on the long-standing commitment of the Health Department to provide public access to its many data sources as well as existing collaborations between the Health Department and academic researchers. The goals of HD4NYC are to (a) produce actionable, policy-relevant research that will advance health equity and (b) advance the careers of a diverse group of early- and mid-career investigators from NYC metropolitan academic institutions and the Health Department.HD4NYC is based on the research working group model that has been shown to foster multi-institutional collaboration, high impact research, and career development of early- and mid-career investigators in other settings, such as the Cardiovascular Health Study (CHS) and the the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) , 6.HD4NYC promotes collaboration between academic and applied public health researchers.HD4NYC facilitates access to a breadth of data sources, including Health Department survey and surveillance data.HD4NYC focuses on the complex and interrelated social, economic, and environmental drivers and consequences of health inequities.HD4NYC supports the translation of research findings into policy change.Our program differs in important ways from prior applications of the working group model:The Health Department and NYAM provide shared leadership for the program and dedicated program staff, including a program coordinator at NYAM and a program coordinator and data manager at the Health Department. These roles support accessing and analyzing data, navigating the Heath Department, connecting to external stakeholders, project management, and other logistical and administrative needs. Each working group is co-led by senior mentors from the Health Department and an academic institution.We used multiple strategies to recruit a diverse pool of academic and Health Department investigators. We recruited investigators and co-leads within the Health Department via a variety of agency networks. Potential working group topic areas were identified based on applicants’ interests, agency priorities, and availability of Health Department data. After identifying possible working group topics, we invited leaders in health equity to nominate early career academic investigators, conducted an environmental scan, and sent email blasts. We assessed applicants on the following attributes: demonstrated commitment to health equity, policy-relevant research, and team science; analytical skills; and alignment of interest with the initial themes. For academic investigators, we also assessed publication and funding productivity. For Health Department investigators, we considered how HD4NYC would facilitate career growth and skill development, as well as the applicant’s program to ensure representation from across the agency.We accepted 19 academic investigators and two academic co-leads into HD4NYC. These researchers represent 14 academic institutions in the NYC metropolitan area and have diverse expertise, including public health, medicine, nursing, engineering, and psychology. We accepted ten Health Department investigators and two co-leads from eight Health Department divisions into HD4NYC. After 2 years, 90% of the investigators remain engaged in the program.We ultimately established two working groups: one focused on birth and childhood equity and the other focused on the health of marginalized populations. Each working group meets monthly to review research progress, obtain peer and co-lead feedback on research, and stay abreast of program goals. Working groups were further divided based on initial subthemes of interest, with three in each working group . Subgroups meet on a biweekly or weekly basis to collaborate on research projects. The initial subgroups focused on the following topics: maternal/infant health, children’s environmental health, health of children from immigrant families, policy evaluation, stigma and discrimination, and criminal legal system-involved populations.HD4NYC facilitated orientation to Health Department data in several ways, such as creating one-page summaries of select Health Department surveys and surveillance systems; connecting researchers to key staff that manage datasets aligned with HD4NYC subthemes; and summarizing data access procedures. We supported data access by registering academic investigators as Health Department volunteers, allowing for access to Health Department buildings and computers. We also offered software trainings, arranged for remote data access, and facilitated the completion of Data Use Agreements. Finally, our data manager ran descriptive statistics to guide development of research questions and analytic plans.To support the professional development of investigators and enhance the quality and policy relevance of HD4NYC research, we hosted quarterly seminars that enabled investigators to interact with national and local health equity leaders, including prominent health equity researchers, directors of local community-based organizations, and representatives from potential funding mechanisms. Mentorship is a central component of the program for both Health Department and academic investigators. HD4NYC co-leads facilitate working group meetings, guide the development of research questions, review and provide feedback on project proposals and research products, and provide as-needed one-on-one or small group mentorship.We invited Health Department staff whose work aligned with investigator interests to join working group and subgroup meetings to inform project development. In some instances, they joined the projects as collaborators. While not explicit in the original program model, we quickly recognized the need to involve other governmental and community-based stakeholders in the collaborative research process. To start, we held a half-day stakeholder workshop, attended by invited representatives from community-based organizations and other city agencies whose work aligned with the initial six projects. HD4NYC subgroups have continued engagement in a variety of ways, including holding subsequent feedback sessions to interpret preliminary results, guest-presenting on coalition webinars, involving stakeholders in weekly project meetings, inviting stakeholders to co-author publications, and sharing findings in ways useful to community-based stakeholders .We used a combination of surveys and focus groups to assess the appropriateness, effectiveness, efficiency, and impact of program components, and to identify gaps in the program and priorities for improving HD4NYC. Overall, the working group model and program components were reported as valuable. HD4NYC has produced publications of peer-reviewed manuscripts, a grant-funded ancillary study, and ongoing partnerships with community and governmental stakeholders. Reported limitations included a lack of funding for academic investigators and adequate resources and time for equitable community stakeholder engagement.We now provide an overview of the subset of HD4NYC research projects included in this special section. The enclosed papers address important upstream determinants of health including criminal justice, tobacco control, environmental exposures, and access to healthcare.Thompson, Baquero, and colleagues examined experiences of policing and criminal legal system policies and their associations with physical, mental, and behavioral health outcomes . The study found that those stopped by the police, abused by the police, and those experiencing discrimination reported higher levels of adverse health outcomes, and these associations were most commonly observed among Black NYC residents and residents ages 24–44. This study strengthens the body of literature around health and policing by examining validated and comprehensive measures of health at the individual level in a representative sample of NYC residents. These findings may inform ongoing policy discussions in NYC and nationally regarding policing and criminal legal system reforms [There is mounting evidence that criminal legal system policies and practices differentially impact some racial and ethnic groups, such as Black and Latinx communities; these differences may contribute to health inequities . Thompso reforms .Li and colleagues constructed a micro-simulation model to predict cardiovascular disease outcomes and related healthcare cost savings if a menthol ban was implemented in NYC. The model projected that a menthol ban policy would result in substantial reductions in cases of myocardial infarction and stroke among adult smokers in NYC overall, and subgroup analyses suggested even greater reductions in adverse cardiovascular outcomes among women, specifically Black women [Well-timed, rigorous policy evaluations can provide evidence to make equity-informed policy decisions and inform the prioritization of resources. ck women .Maru, Glenn, and colleagues collaborated closely with community stakeholders to examine utilization of maternal healthcare services before, during, and after pregnancy among immigrant mothers in NYC from 2016 to 2018. The authors found lower utilization of preconception healthcare and dental cleaning during pregnancy among immigrant women, particularly among immigrants that recently arrived to the USA. The authors also found substantial variation by region of origin. These findings can help target efforts to address inequities in maternal healthcare access. The investigators are collaborating with government and community stakeholders to translate their findings into policy and practice [There is growing evidence that limited access to healthcare for populations that are marginalized is an important determinant of health. In NYC, half of all births are to immigrant mothers, yet there is little research available on immigrant maternal healthcare utilization. practice .Bajwa, Khan, and colleagues used cluster analysis that grouped children based on socioenvironmental and housing factors at individual and neighborhood levels to better understand the major patterns of these exposures and their relationship to asthma exacerbations. The authors found three neighborhood level factors that predominantly drove cluster formation and differed in asthma outcomes: renting homes, high-density buildings, and older buildings. This information may help target interventions to reduce asthma disparities among children in the city [While many environmental exposures and socioeconomic factors are known to increase the risk of asthma exacerbations – the leading cause of pediatric hospitalizations and emergency department visits in NYC – they are not commonly studied together. the city .HD4NYC research projects not included in this issue also address important determinants and consequences of health inequities, such as bullying among LGBTQ youth of color and trends in health service utilization among children from immigrant families.We have successfully developed and launched a unique public-private partnership that combines collaboration, access to data, and mentoring, using a working group model, to advance health equity research and promote the careers of early- and mid-career academic and applied public health researchers. Working groups focused on marginalized populations and birth and childhood equity established six subtheme groups that have conducted rigorous and impactful research utilizing 10 datasets from the Health Department and other agencies, most in collaboration with community stakeholders. The reports included in this issue reflect the initial products of four of the subtheme groups. In April 2021, the Robert Wood Johnson Foundation awarded a grant to continue HD4NYC for a third year. During this time, we have formed a new working group on COVID-19 health inequities and are focusing on strengthening community engagement, translating research findings for policy change, and sustaining collaborative research.


Although physical and sexual abuse exposure is a well-established risk for poor health, the dimensions of abuse associated with health among socially vulnerable adolescent girls and young women (AGYW) remain underexamined. This article describes associations between combinations of abuse type and timing with mental health, substance use, and sexual risk outcomes among a sample of 499 AGYW (aged 16 to 19) who had left school early and were recruited for a cluster randomized trial in Cape Town, South Africa. Approximately one-third  of participants reported lifetime abuse. Exposure to more than one type of abuse was associated with increased risk of depression  and anxiety , and greater odds of polydrug use  and substance-impaired sex . Exposure to multiple types of abuse during childhood/early adolescence and again in late adolescence was associated with increased risk of depression , anxiety , and polydrug use . Findings underscore the need for trauma-informed interventions that reduce mental health, substance use, and sexual risks among AGYW who have experienced multiple forms of abuse and recurrent abuse. Like many low- and middle-income countries (LMICs) ,2, mentaIf left unaddressed, these mental health and substance use concerns may have lifelong health and socioeconomic sequelae for AGYW. Untreated mental and substance use concerns during adolescence increase risk for mental disorders in adulthood ,19, as wThese prior findings underscore the potential value of incorporating early interventions to prevent or delay the onset of mental health and substance use disorders into HIV prevention programing for AGYW ,30. At pAdverse childhood experiences—including racial discrimination, socioeconomic adversity, and physical and sexual abuse—are well-established transdiagnostic risks for mental health and substance use concerns in adolescence and early adulthood ,35, withThe relationship between multiple types of abuse exposure and recurrence of abuse on mental health outcomes remains underexplored, with available evidence being inconclusive and contradictory ,44,45. FThis article contributes to the emerging literature on how combinations of abuse type and timing contribute to mental health, substance use, and sexual risk among out-of-school AGYW. More specifically, it aims to explore associations between abuse type and developmental timing of abuse with mental health, substance use, and sexual risks for HIV in a sample of socially vulnerable AGYW in Cape Town, South Africa.This article analyzes baseline data from the Young Women’s Health CoOp (YWHC) study, a cluster randomized trial comparing the efficacy of the YWHC intervention with standard HIV counselling and testing (HCT) for reducing substance use and HIV risk behaviors among AGYW with increased risk for HIV in Cape Town, South Africa . The trial methods are described fully elsewhere .Between November 2016 and November 2018, 500 AGYW were recruited from 24 disadvantaged and geographically distinct communities (clusters) in Cape Town. Peers (women aged 18 to 24 who lived in the selected communities) worked together with the study outreach staff to market the study in parts of these communities with high population density, and where young women congregated, such as hair salons. Marketing involved posting study fliers, distributing recruitment cards, and talking to young women and other community members about the study. Potential participants were individually and privately screened for eligibility by outreach staff .Young women were eligible for study inclusion if they were aged 16 to 19, lived in a study community, reported consuming at least two alcoholic drinks or other drug use on a weekly basis over the past 90 days, reported having discontinued school for at least 6 months, were not currently in school and had not completed school, and reported condomless sex with a male partner in the past 90 days. Young women who were eligible and interested in participating were provided with transportation to the study’s research site for study enrollment. At this appointment, study staff confirmed the participant’s eligibility before obtaining their written informed consent for study participation. Women who were aged 16 or 17 provided written informed assent to participate, with consent for their participation being obtained in loco parentis by a trusted woman from their community who was at least 25 years of age . After oAfter this interview, field staff collected urine samples to test for rapid illicit drug and pregnancy screening. A breathalyzer was used to assess recent alcohol use. We used a 5-panel drug screening test to detect cocaine, methamphetamines, amphetamine, opioid, and cannabis metabolites, and a single panel test to assess for methaqualone (Mandrax) use. After completing this appointment, participants were provided with transport to their neighborhood, and were given a gift card to thank them for their time .The following questions assessed lifetime experiences of physical and/or sexual abuse: “Has anyone ever physically abused you ?” and “Has anyone ever pressured or forced you to have sex against your will?” Responses to these two questions were used to create an exposure to lifetime abuse variable, with the following responses: no abuse; physical abuse without sexual abuse; sexual abuse without physical abuse; and both physical and sexual abuse.n = 51), we created a single variable to capture any abuse during childhood or early adolescence. Abuse during childhood or early adolescence was considered present when participants reported any abuse exposure before the age of 16. Abuse during late adolescence was considered present when participants reported abuse in the 6 months prior to study enrollment. Recurrent exposure was defined as exposure to abuse during both childhood/early adolescence and late adolescence.To better understand temporal associations between exposure to physical and sexual abuse and symptoms of mental ill-health, we examined the developmental timing of abuse. Developmental timing of abuse was assessed through items examining the age at which physical and/or sexual abuse first occurred and abuse in the 6 months prior to study enrollment. Given the small number of participants reporting physical and/or sexual abuse before the age of 16 (We used the 7-item Texas Christian University (TCU) depression scale to assess depression symptom frequency in the 90 days prior to study enrollment . OriginaThe results from drug testing were used to assess for recent polydrug use—a pattern of drug use associated with elevated risk of mental and physical health problems, including risk for HIV ,49. Polyp < 0.05. We used Stata’s survey analysis platform to account for clustering by community. Using a complete case analysis, a total of 499 of the 500 participant observations were included. We estimated the prevalence  of each combination of abuse type for each developmental period and across the lifespan. Next, we conducted a series of multivariate linear and logistic regression models to estimate associations between each mental health, substance use, and sexual risk outcome and type, combination, and timing of abuse exposure. All models adjusted for participant age and race. We first estimated the effect of any abuse exposure on each outcome (Model 1). Following this, we estimated: the effect of type of abuse (Model 2); a combination of type of abuse (Model 3); and the timing of abuse—childhood/early adolescence, late adolescence, or both developmental periods (Model 4). Finally, we examined the effect of both combinations of type of abuse and timing of abuse (Model 5). Each model was estimated for risk of depression, anxiety, polydrug use, and substance-impaired sex. The findings are presented as odds ratios (OR) or β coefficients with 95% CI.All analyses were conducted using Stata 16, with statistical significance set at Overall, 33.5%  of the sample reported experiencing any lifetime physical and/or sexual abuse, 21.4%  of the overall sample reported abuse during childhood or early adolescence, and 23.8%  reported abuse during late adolescence. Irrespective of developmental period, physical abuse was more frequently reported than sexual abuse . OverallIn regression analyses examining associations between any abuse exposure and mental health, substance use, and sexual risks Model 1, , any abuIn models examining combinations of abuse (Model 3), exposure to both physical and sexual abuse was associated with heightened risk of depression  and anxiety , and with greater odds of polydrug use  and substance-impaired sex . Exposure to one form of abuse, whether physical or sexual, was not significantly associated with any of the four outcomes .Among participants who reported exposure to any type of abuse, 28.6%  reported abuse during childhood or early adolescence only, 35.7%  reported abuse during late adolescence only, and 35.1%  reported abuse in both developmental periods. both physical and sexual abuse in childhood or early adolescence and again during late adolescence increases risk of depression  and anxiety . When type and timing of abuse exposure were considered together, exposure to physical and/or sexual abuse during late adolescence (in the absence of childhood abuse) did not heighten mental health or sexual risk. Exposure to physical abuse during this developmental period was associated with greater odds of polydrug use . Exposure to abuse during childhood/early adolescence in the absence of abuse during late adolescence was associated with greater risk of depression  and anxiety .We estimated a model that includes type and developmental period of abuse . The finAlthough physical and sexual abuse are known risks for mental health and substance use concerns among young people ,35,36, sSimilar to findings from population and longitudinal studies from high-income countries ,53, our Early interventions that allow for the efficient use of South Africa’s severely constrained resources for mental health and substance use services are more likely to gain traction with policymakers and service planners ,33. PoteOur findings further suggest that AGYW exposed to multiple forms of abuse and who experience recurrent abuse may be important to prioritize for early interventions. In this study, AGYW exposed to multiple types of abuse were at greater risk for mental health and substance use concerns and sexual risk for HIV than those with a single type of abuse exposure. Risk for internalizing problems such as depression and anxiety seemed particularly elevated for AGYW exposed to multiple forms of abuse during childhood/early adolescence. Other studies from high-income settings also described the cumulative effect of exposure to multiple types of abuse on mental health outcomes ,56. ThisSeveral study limitations need to be considered when interpreting these findings. First, the sample comprised AGYW recruited from 24 disadvantaged communities as part of a randomized controlled trial. Trial eligibility recruitment and geographic location may restrict the generalizability of the findings to AGYW in other parts of the country, and inferences about the prevalence of abuse in the general population of AGYW cannot be made. Second, abuse exposure was assessed retrospectively via self-report: recall and response biases may have led to these exposures being underestimated. However, questions were carefully piloted, and were asked via ACASI, a method known to improve accuracy of reporting on sensitive issues such as sexual abuse . Third, The high rates of physical and sexual abuse exposure in study participants suggest that current efforts to prevent abuse against socially vulnerable AGYW in South Africa are insufficient. Given the findings of elevated risk for mental health and substance use concerns among AGYW who have been abused, there is an urgent need to introduce and scale up evidence-based strategies for preventing all forms of interpersonal violence against children and AGYW in South Africa. This is particularly important given the dearth of treatment for the mental health sequelae of abuse in this setting. The findings of high rates of abuse recurrence and associations between abuse recurrence and greater risk to mental and behavioral health emphasize the need to develop and implement early interventions that mitigate against the short- and long-term consequences of abuse, and equip AGYW with strategies to reduce risk of recurrent exposure to violence. Additionally, consideration should be given to routinely screening AGYW for abuse exposure when they present for sexual and reproductive health services. AGYW who report histories of abuse may benefit from mental health and substance use interventions that are currently being integrated into HIV and other sexual and reproductive health services ,15,16. H


Pathological remodelling of the myocardium, including inflammation, fibrosis and hypertrophy, in response to acute or chronic injury is central in the development and progression of heart failure (HF). While both resident and infiltrating cardiac cells are implicated in these pathophysiological processes, recent evidence has suggested that endothelial cells (ECs) may be the principal cell type responsible for orchestrating pathological changes in the failing heart. Epigenetic modification of nucleic acids, including DNA, and more recently RNA, by methylation is essential for physiological development due to their critical regulation of cellular gene expression. As accumulating evidence has highlighted altered patterns of DNA and RNA methylation in HF at both the global and individual gene levels, much effort has been directed towards defining the precise role of such cell-specific epigenetic changes in the context of HF. Considering the increasingly apparent crucial role that ECs play in cardiac homeostasis and disease, this article will specifically focus on nucleic acid methylation (both DNA and RNA) in the failing heart, emphasising the key influence of these epigenetic mechanisms in governing EC function. This review summarises current understanding of DNA and RNA methylation alterations in HF, along with their specific role in regulating EC function in response to stress . Improved appreciation of this important research area will aid in further implicating dysfunctional ECs in HF pathogenesis, whilst informing development of EC-targeted strategies and advancing potential translation of epigenetic-based therapies for specific targeting of pathological cardiac remodelling in HF. Heart failure (HF) is a complex clinical syndrome arising from any structural or functional abnormality, resulting in inadequate cardiac output to support physiological demand. HF is the leading cause of hospitalisation in patients aged > 65 years, carrying considerable economic cost and regarded as a major public health burden . The HF HF is initiated by acute or chronic injury to the myocardium and evokes a diverse and complex array of cellular responses involving resident cardiomyocytes, fibroblasts, and endothelial cells (ECs), and infiltrating immune cells, which initially repair damaged tissue and maintain cardiac function. Over time, exaggerated wound-healing responses including cardiomyocyte hypertrophy, fibrosis and inflammation lead to aberrant remodelling and cardiac dysfunction –8. Such ECs line the interior of blood and lymphatic vessels, forming a metabolically active barrier between the circulation and smooth muscle, and playing a key role in the regulation of physiological processes, such as angiogenesis, wound healing, smooth muscle cell proliferation, fibrosis and inflammation . The endIt is well established that EC dysfunction plays a central role in HF development and progression , whilst NOS3 (eNOS) , 3 hypomethylated  and 3 microRNAs ), with significantly altered levels consistent with the direction of methylation identified in the particular HF patient sub-group  and homocysteine), resulting in enhanced translation and protein expression both in vitro and in vivo and associated with increased leukocyte adhesion and formation of allograft arteriosclerosis, which was attenuated by genetic deficiency of NSUN2 [SHC mRNA that was accompanied by premature senescence and enhanced expression of key proteins, such as SHC, TP53 and p16 [The influence of RNA cytosine methylation on EC function is becoming increasingly apparent, especially in the context of metabolic dysfunction and inflammation. For example, NSUN2 is reported to methylate of NSUN2 . Similar and p16 . There i and p16 , althougRemarkable progress has been made towards understanding molecular mechanisms underlying changes in both DNA and RNA methylation in cardiovascular development and disease, especially in the context of HF. Whilst the majority of these pioneering studies assessed DNA and RNA methylation in cardiac tissue, there is now a major shift towards dissecting the relative contribution of epigenetic changes within individual cell types in HF. In this regard, ECs line the entire vasculature where they perform an essential role in maintaining homeostasis; they are particularly important in the heart where they represent the largest cell population forming an active barrier between the coronary circulation and myocardium. It is therefore unsurprising that dynamic changes in nucleotide methylation in response to injurious stimuli, such as hypoxia and metabolic dysfunction (e.g. hyperglycaemia), have been implicated in promoting EC dysfunction and HF Fig. .Fig. 3ScBeyond the scope of this review, it is appreciated that DNA and RNA methylation interact with and form complex regulatory networks with other epigenetic modifications, including those to histone tails, ATP-dependent chromatin remodelling complexes, and other noncoding RNA species (miRNAs and lncRNAs), to dynamically modulate chromatin structure and gene expression. One example of such cooperation in the context of ICM is indicated by interaction between enhancer of zeste homologue 2  and DNA methylation to regulate ischaemia-induced expression of metabolic enzymes and transcription factors in the heart . With spIt is well established that ECs within individual organs are not homogenous, with their expression profile and activity differing depending on arterial, venous, capillary, and sinusoidal origin. Such heterogeneity includes differences in cellular morphology, production of ECM, and tight junction formation –185, dueThe attraction of these epigenetic changes from a therapeutic perspective lies in their inherently reversible nature along with potential for pharmacologically targeting and modulation. There are currently two inhibitors of DNA methylation, 5aza and 5azadC, clinically approved for treatment of haematological malignancies such as acute myeloid leukaemia and myelodysplastic syndromes. Whilst both of these agents beneficially impact pathological cardiac remodelling in preclinical models of HF , 50, 51,TET1 specifically reduced cytosine methylation at DMRs in the TNF-α gene leading to enhancement of expression [Although there is major therapeutic promise regarding use of apabetalone for treatment of post-acute coronary syndrome in type 2 diabetic patients with cardiovascular disease, currently under evaluation in the BETonMACE phase III trial , there apression . As suchpression . Such teIn conclusion, whilst the future of epigenetic therapy for HF is promising, further research is clearly required to elucidate precise underlying mechanisms, including specific involvement of nucleic acid methylation in EC dysfunction and its contribution to pathological cardiac remodelling. Answering such fundamental questions is likely to inform development of EC-targeted strategies and translation of epigenetic-modifying therapies for clinical benefit in HF.


Compared to sole crops, intercropping—especially of legumes and cereals—has great potential to improve crop yield and resource use efficiency, and can provide many other ecosystem services. However, the beneficial effects of intercrops are often greatly dependent on the end use as well as the specific species and genotypes being co-cultivated. In addition, intercropping imposes added complexity at different levels of the supply chain. While the need for developing crop genotypes for intercropping has long been recognized, most cultivars on the market are optimized for sole cropping and may not necessarily perform well in intercrops. This paper aims to place breeding targets for intercrop-adapted genotypes in a supply chain perspective. Three case studies of legumes and cereals intercropped for human consumption are used to identify desirable intercrop traits for actors across the supply chains, many of which are not targeted by traditional breeding for sole crops, including certain seed attributes, and some of which do not fit traditional breeding schemes, such as breeding for synchronized maturity and species synergies. Incorporating these traits into intercrop breeding could significantly reduce complexity along the supply chain. It is concluded that the widespread adoption and integration of intercrops will only be successful through the inclusion and collaboration of all supply chain actors, the application of breeding approaches that take into account the complexity of intercrop supply chains, and the implementation of diversification strategies in every process from field to fork. The practice of intercropping legumes and cereals is predicted to drive the sustainable intensification of food supply chains ,b. CompaEach legume–cereal intercrop is part of a dedicated supply and value addition chain (referred to here as supply chains) with different end uses and actors requiring different outcomes and breeding targets. The major functions of legume–cereal intercrops from industrialized agriculture are animal feed in the form of grain, whole-crop forage, or silage. Their use for wholegrain and processed food products is currently small scale, although this is changing rapidly , and legThe benefits of intercrops for crop yields and other outcomes are often dependent on the specific genotypes used , emphasiIntercropping currently imposes added complexity at different levels of the supply chain , which iHere, three case studies of intercrop supply chains were used to: (i) determine challenges at each level of the supply chain, (ii) identify relevant trait categories to help overcome these challenges, and (iii) suggest potential breeding targets for “intercrop-adapted” genotypes. Finally, approaches and methods with potential to improve breeding for intercropping and increase supply chain acceptance are discussed.The three case studies draw on input from relevant stakeholder groups, including breeders, crop scientists, farmers, and processors. This was compiled from authors’ experience, exchange with relevant stakeholders in Germany, France, Scotland, and Denmark, and a workshop held at the first European Conference on Crop Diversification . Cases were selected among several candidates based on the criteria that they (i) be currently relevant legume-based intercrops for human consumption in an author’s country, (ii) represent different types of supply chains, and (iii) reveal some experience with supply chains actors.Case study 1: Winter wheat intercropped with pea in Germany. While traditionally grown for fodder, this combination is gaining attention for its potential to improve wheat baking quality. Many farmers are currently reluctant to grow this intercrop due to lack of expert advice and experience within farmer networks, as well as suitable pea cultivars for mixing with winter wheat.Case study 2: Pea–barley intercropping in Scotland, using barley for distilling and pea protein by-products as a food ingredient. Barley is grown on over 60% of the arable land in Scotland and is used for brewing and distilling and animal feed, which are critically important to Scotland’s economy and culture. Pea intercropping creates an opportunity to diversify the arable system.Case study 3: Lentil intercropped with cereals for human consumption based in France, Denmark, and Germany. Lentil is a high-value food crop and intercropping with cereals in organic systems provides weed suppression and structural support resulting in increased lentil height and more efficient harvest.Crop traits desirable to each supply chain actor were compiled for each case study , revealiSeveral of the breeding traits identified as relevant within the supply chain for these intercrops  are equaSelection of these traits for intercrops is particularly challenging due to the added complexity of managing crop species interactions , and theThe main advantage of intercrops is often described as being the result of the “4C effects”  correspoSelection for “species synergy” , that isMany of the breeding targets identified within legume–cereal supply chains  have impResistance to seed splitting in legumes, for example, is important for both sole crop and intercrop production , but theSynchronization of ripening times between species and the reduction of pod shattering and seed splitting in legumes are important not only to improve harvesting and seed sorting efficiency, but also to reduce additional post-harvest handling, such as drying .Selection for increased lentil canopy height would improve mechanical pod harvesting efficiency , while aWhile quality, nutritional, and sensory characteristics are breeding targets that are important in sole crops as well as intercrops, intercropping will often influence quality parameters. Cereal grain protein can be improved through intercropping with legumes , althougAlthough the benefits of diversified diets are well known , highligOur assessment has identified several desirable intercrop traits for actors across supply chains, including several seed attributes not targeted by modern breeding for sole crops, including synchronized maturity and species synergies. Dedicated crop improvement strategies and collaborations are evidently needed for intercropping to support the sustainable intensification of food and feed supply chains.Crop breeding priorities are often set by the dominant industry demands for characteristics, such as disease resistance, ease of harvest, or processing quality. Intercropping requires consideration of additional traits; while this might add to breeding complexity, it presents opportunities to reduce complexity for other supply chain actors and encourage intercrop innovations in desirable traits and end products, while contributing to agricultural sustainability.Taking advantage of potential intercrop innovations will require the involvement and empowerment of all supply chain actors, including regulators who incentivize farmers to adopt legume–cereal intercrops . Processors might be more willing to challenge purity requirements when there is a close working relationship with producers . SmallerFrom the breeder’s perspective, the intercrop traits presented above have differing levels of complexity, implying differences in genetic background, variable importance of trade-offs between traits, and a need for different breeding schemes. We identified three categories of traits: (i) general agronomic traits, such as disease resistance and grain yield; (ii) specific traits for intercropping success due to their role in technical, quality, and other downstream processes, including ripening time and seed color; and (iii) complementary traits related to species synergy during the growth period, for example, “mixing ability” and “species compatibility,” which are more complex, not yet clearly defined and undoubtedly involve more genes than the other categories.These different breeding targets present novel opportunities and challenges for existing breeding programs, especially when considering plant–plant and plant–environment interactions . BreedinRecent advances in breeding tools and approaches highlight the growing interest in their potential use for intercrop breeding. Application of Function-Structural Plant Models (FSPM) and process-based minimalistic models could significantly reduce the complexity of intercrop breeding, and minimize the need for experimental evaluation of multiple crop genotype combinations and spatial designs . While sParticipatory breeding has been successful at increasing yields of several crops  and thisWhile the diversification of agroecosystems through intercropping is gaining attention, the widespread adoption and integration of intercrops will only be successful through the inclusion and collaboration of all supply chain actors, and the application of different breeding approaches. This requires challenging the “predominant monoculture agricultural paradigm” prevalent in breeding programs , and impThe original contributions presented in the study are included in the article/supplementary material, and further inquiries can be directed to the corresponding author.LK and AK conceived the idea. LK, OW, LB, and PI collated case study information. LK, OW, and AK wrote the manuscript, with input from all authors. All authors contributed to the article and approved the submitted version.www.bakwert.de). The research work by MW at the SLU was partly funded by a grant from the Swedish research council Formas (grant number 2020-01099).The authors were supported by funding from the European Union’s Horizon 2020 research and innovation program under grant agreement No. 727284 , No. 727973 (TRUE: PI), No. 727929 (TOMRES: PI), and No. 727217 . The James Hutton Institute (AK and PI) is supported by the Rural & Environment Science & Analytical Services (RESAS), a division of the Scottish Government. The research work of the Department of Ecological Plant Protection, University of Kassel (OW and MF) is also supported through the project BAKWERT “Bewertung und Akzeptanz heterogener Weizenpopulationen in ökologischen Wertschöpfungsketten” funded through the German Federal Office for Agriculture and Food (BÖLN—Grant agreement 2819OE033; GR-T was employed by company Nordic Maize Breeding.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The increase in extreme climate events such as flooding and droughts predicted by the general circulation models (GCMs) is expected to significantly affect hydrological processes, erosive dynamics, and their associated nonpoint source (NPS) pollution, resulting in a major challenge to water availability for human life and ecosystems. Using the Hydrological Simulation Program–Fortran model, we evaluated the synergistic effects of droughts and rainfall events on hydrology and water quality in an upstream catchment of the Miyun Reservoir based on the outputs of five GCMs. It showed substantial increases in air temperature, precipitation intensity, frequency of heavy rains and rainstorms, and drought duration, as well as sediment and nutrient loads in the RCP 8.5 scenario. Sustained droughts followed by intense precipitation could cause complex interactions and mobilize accumulated sediment, nutrients and other pollutants into surface water that pose substantial risks to the drinking water security, with the comprehensive effects of soil water content, antecedent drought duration, precipitation amount and intensity, and other climate characteristics, although the effects varied greatly under different rainfall patterns. The Methods and findings of this study evidence the synergistic impacts of droughts and heavy rainfall on watershed system and the significant effects of initial soil moisture conditions on water quantity and quality, and help to guide a robust adaptive management system for future drinking water supply. Precipitation shifts alter the volume and timing of storm and snowmelt runoff into water bodies, which has triggered hazards with increasing soil erosion and pollutant export in watersheds3. Rising temperatures increase both evaporative and transpiration losses from land and water surfaces, potentially reducing annual runoff and streamflow, which will present a challenge of insufficient water-supply capacity to meet water demands for ecosystem, agriculture, domestic, and industrial use. Furthermore, warmer air can trigger more rainfall extremes because it is associated with more atmospheric moisture and local convective events that provide more potential energy to drive rainstorms4. The frequency of long-term low rainfall is predicted to increase by the end of the twenty-first century6. Flash flood hazards and rainfall’s erosive power will increase if an increase in precipitation is accompanied by increases in drought duration and rainfall intensity, and nutrient losses and pollutant export will be further aggravated.Changing climate in recent decades has significantly increased extreme events at global scale. Some 27 indices for climate extremes have been recommended by the ETCCDMI  configurations. However, a clear understanding of the interaction between extremes and water quality impairments is integral to climate-change mitigation and adaptation12.Average temperature and precipitation are not the only factors that affect watershed systems. Extreme climate conditions such as sustained droughts, extreme flooding, and intense rainfall events have major effects on hydrology and water quality15. Generally, the hydrological and water quality responses to a rainfall or drought event are determined by topographic, soil, and climate drivers. A systematic analysis of influencing factors incorporating the impacts of climate extremes is imperative to promote sustainable development and conservation of water resources.During droughts, seasonal changes in antecedent moisture conditions, crop growth stage, agricultural practices, and climate characteristics can interactively affect surface runoff, sediment, nutrient export, and waterborne pathogens from agricultural watersheds. The impacts of drought on hydrology and water quality is highly complex, depending on the combination of weather conditions and land-surface characteristics that precede, co-occur with, or follow a long drought period19, such as the Soil and Water Assessment Tool (SWAT) model20, the Hydrological Simulation Program-Fortran (HSPF) model22, the Storm Water Management Model (SWMM)23, and the Agricultural Non-Point Source Pollution Model (AGNPS)24. The HSPF model is a semi-distributed, comprehensive model with an integrated framework of three modules for continuous simulation of various hydrological and associated water quality processes from pervious land areas (PERLND), impervious land areas (IMPLND), and stream channels (RCHRES) in daily and sub-daily time series25. It has been demonstrated to be an effective tool to evaluate short and long-term point and nonpoint source (NPS) pollution and the degradation and transport of chemical contaminants across watershed and regional scales, along with the integrated simulation of land-soil runoff processes26. Considering that extreme climate events occur over very short periods of several hours or days, the HSPF model was selected from existing watershed models due to its ability to run at sub-daily scales. Several modeling studies have also indicated that the HSPF is a reliable tool to address the effects of BMPs within watersheds under various climate change scenarios28, which is critical in developing adaptation strategies for climate extremes. With this in mind, this study used the HSPF model to reveal the impacts of climate extremes on watershed hydrology and water quality.Based on the downscaled outputs of general circulation models (GCMs), hydrological and watershed models have been extensively used in studies on climate variability impact29. Hence, an upstream catchment of the Miyun reservoir was selected to perform a reliable evaluation of the impacts of extreme climate event on hydrology, NPS pollution and to analyze the effects of interacting factors along with climate variability. The main aim of this study was to seek hydrological and water quality responses to extreme climate (heavy precipitation and drought) on the basis of assessing the impacts of interacting factors on hydrology and NPS pollution. Therefore, the objective of this study can be achieved by completing the following tasks: 1) evaluate the variability of extreme climate in the future, including number of heavy precipitation days ≥ 25 mm, number of rainstorm days ≥ 50 mm, and periods of excessive dryness; 2) assess the potential impacts of extreme precipitation on watershed hydrology and NPS pollution; 3) assess the potential impacts of drought on watershed hydrology and NPS pollution; 4) analyze the interacting factors for watershed hydrology and water quality in response to drought conditions. The results evidenced the substantial impacts of climate changes or extremes on watershed systems, and highlighted the significant effects of initial soil moisture conditions on water quantity and quality.The Miyun Reservoir is the most important surface drinking water source for China’s capital, Beijing, providing domestic, industrial, and commercial water for a large population of 21.75 million. The drainage watershed of the Miyun Reservoir is managed with the aims of sustainably supplying clean water and improving water quality. Changes in water balance and water quality in the upstream catchment would directly challenge water supply and rapid economic development in Beijing. Generally, a watershed is more vulnerable to extreme events because of the transient devastating effects of rapid watershed processes on the water resource and the lack of retention time and the limited space for pollutant dilution or decomposition30.The framework for seeking potential impacts of extreme precipitation and drought on watershed hydrology and NPS pollution and identifying interacting factors is shown in Fig. 31.The HSPF model is contained in the U.S. Environmental Protection Agency (USEPA) Better Assessment Science Integrating Point and Nonpoint Sources (BASINS) decision support tool, which incorporates the Geographic Information System (GIS). The HSPF model is a conceptual, dynamic, process-based watershed model for simulating land-surface and subsurface hydrological and associated water quality processes. It has been extensively used around the world for many purposes, including watershed planning and management, flood control, water quality management , evaluation of BMPs, and assessment of climatic regimes and land-use change impacts25. Model calibration and validation were performed based on the observed data during 2014–2015, combined with an automatic calibration program (the Model-Independent Parameter Estimation (PEST) program) and the Bacterial Indicator Tool for parameter adjustment. More details of the model description, data availability, and calibration and validation of hydrological and water quality processes in the TMC  and Nash–Sutcliffe efficiency (Ens)) indicated satisfactory performance of the HSPF model in simulating streamflow and water constituents in the study watershed , solar radiation, wind speed, and cloud cover. Table 33 to reveal potential extreme effects on watershed systems. To reduce systematic biases in models, simulated climate datasets were corrected by a distribution-based bias-correction method, which was given in Hempel et al.34. The probability distributions of observations and bias-corrected simulations during 1960–2005 are shown in Fig. Extreme climate projections from 2020 to 2099 were obtained from five GCMs that are recommended in the Inter-Sectoral Impact Model Inter-comparison Project (ISI-MIP), including GFDL-ESM2M, HadGEM2-ES, IPSLCM5A-LR, MIROC-ESM-CHEM, and NorESM1-M  and future period (2020–2099). Projected changes in annual precipitation amount, annual mean temperature, maximum temperature, minimum temperature, maximum consecutive drought days, and frequency of different rainfall patterns was identified by comparing the future climate data with the baseline climate condition. As the model was calibrated and validated, the climate projections were used as input into the HSPF model to identify the impacts of climate change on water balance and quality. Daily precipitation dataset was temporally disaggregated into an hourly time series with the support of historical observed data to provide a better accounting of the short duration of intense rainfall within the HSPF model. That is, the temporal distribution of hourly observed data is extended to that of GCM hourly data for the corresponding analog day. The disaggregated downscaled hourly precipitation is calculated as follows:Three major extreme events were considered in this study: intense precipitation events with depth greater than 25 mm but less than or equal to 50 mm, intense precipitation events with depth over 50 mm, and long-term droughts.2. The landforms are mainly hilly, with an elevation range of 228–761 m, and nearly half of the catchment has slopes greater than 25°. Land use in the TMC is predominantly forest , cropland (13.62%), dry fruit plantations or orchards (26.52%), and rural residential areas (2.07%). The climate is of semi-humid continental monsoon type, with the mean annual temperature and precipitation being 14.6 °C and 660 mm respectively. Because point sources are rare, pollutants are exported mainly from diffuse sources and flow naturally to the outlet. As an upstream catchment of the Miyun Reservoir, the water quality of the TMC should be improved, especially during rainfall events, with strict permissible limits that are compliant with the Class III Environmental Quality Standards for Surface Water in China  of 0.998. This suggests that rainfall-runoff is the major factor influencing fecal coliform contamination. Runoff scours topsoil that incorporates intensive manure applications and the waste produced by animals. However, surface runoff and soil loss for individual rainfall events vary widely, depending on antecedent soil moisture conditions such as soil storage and infiltration capacity, precipitation amount, and other factors. This study found that antecedent soil water content was significantly related to runoff generation and soil erosion. An increase in antecedent soil water content resulted in a decrease in fecal coliform export, which indicated that this wet soil had low susceptibility to erosion by raindrops and runoff due to its aggregate stability and compaction. Precipitation amount played an important role in fecal coliform export because precipitation inputs directly correlated with runoff magnitude were found to be the key contributor to fecal coliform loading. After a large rainfall event, less fecal coliform is left on the land surface to be transported to streams, and hence the load was negatively correlated with antecedent precipitation amount . GFDL-ESM2M, HadGEM2-ES, IPSLCM5A-LR, MIROC-ESM-CHEM, and NorESM1-M are recommended in the framework of ISI-MIP, which aims to synthesize climate change impacts on water resources, agriculture and ecosystems in different sectors and at different scales, and to identify the inherent uncertainty in climate models and impact models85. Within the ISI-MIP, only these five GCMs from the CMIP5 driven by multiple RCP scenarios were bias corrected to provide climate forcing for watershed models, which makes it impossible to fully characterize the potential uncertainty ranges by GCMs. However, a greater fraction of the ensemble range coverage can be captured by the five GCMs in the ISI-MIP framework than any other 500 subsets of five GCMs from CMIP5, with median 0.75 and 0.59 across different regions and seasons for temperature and precipitation, respectively, which better represents the range of changes in regional climate86. Numerous previous studies have reported the applicability of climate projections from these five GCMs as input data of watershed models to quantify the impact of climate change on water resources at regional scale89. Although uncertainties are inevitably introduced in the simulated results, we found that all five climate models projected the same changing pattern with different magnitudes in precipitation and temperature (Figs. The climate data for both temperature and precipitation used in the current impact analysis may not be accurate at watershed scale due to the uncertainties arising from multiple sources such as GCM structure, emission scenarios, and downscaling or bias-correction methods90. The uncertainty in model parameters was analyzed in our previous study by parameter sensitivity analysis and model calibration using the PEST program to improve the fit between simulated and observed data32. Furthermore, another important source of uncertainty occur in the modelling process is the errors related to incomplete or biased model structure91. Model structure uncertainty can be examined through the use of multiple simulation tools or the selection of different model structures within the same modelling tool93. Additionally, the HSPF model needs improvement to include the effects of CO2 concentration on hydrological and water quality processes to truly reflect the effects of climate change on watershed systems. Although the uncertainties in HSPF model were not systematically evaluated here, it could be a part of future research.Another potential source of uncertainty is impact models, which can be attributed to model structure and parameters, skill of the modeler, and other inputs required for the simulations. The uncertainty in the input data, including measurement inaccuracy as well as random or systematic errors relating to data management, which is passed on to the simulated results in a form of aleatory uncertainty, can be calculated by generally applicable methods, such as Monte Carlo sampling method, Generalized Likelihood Uncertainty Estimation Method, and Markov Chain Monte Carlo MethodWithout considering all the factors discussed above, simulation results may not be realistic in some cases. Further process-specific research on internal processes would be beneficial to reduce uncertainties. However, the results of this study are useful to identify potential hydrological and water quality responses to different rainfall patterns and ongoing climate change. The findings of this study guide a robust adaptive management system to maintain the sustainability of water resources in the face of long dry spells and extreme precipitation.This study used the HSPF model to assess the potential impacts of rainfall patterns and droughts on watershed hydrology and NPS pollution, based on extreme climate projections obtained from five GCMs. Substantial increases in air temperature, precipitation intensity, frequency of heavy rains and rainstorms, and annual maximum duration of drought were predicted in future climate scenarios. In addition, the interacting factors affecting hydrology and water quality in response to rainfall patterns and drought conditions were identified. Precipitation, as a driving factor, played a major role in water balance and determined the amount of runoff. This caused serious soil erosion, nutrient losses, and outputs of fecal coliform by the interactive effects of raindrop and surface runoff. Hydrology and water quality were particularly vulnerable to short-term transient heavy rain and rainstorm events after a prolonged drought, with the comprehensive effects of antecedent soil water, antecedent drought duration, current precipitation amount and intensity, and antecedent precipitation characteristics. The results of this study can help to reveal the complex interactions of the various processes conditioning the water balance and linking agricultural NPS pollution and can guide a robust adaptive management system for future drinking water supply. Further research will focus on incorporating BMPs into adaptation strategies for climate extremes based on evaluating BMP performance in future climate change scenarios.Supplementary Information.


This article contains data outlining the effects of increased storm intensity on estuarine salt marshes, previously evaluated in Pannozzo et al. (2021), using the Ribble Estuary, in North West England, as a case study. The hydrodynamic model Delft3D was used to simulate various surge height scenarios and evaluate the effects of increasing surge height on the sediment budget of the system. The data shows that an increase in storm intensity (i.e. surge height) promotes flood dominance and triggers a net import of sediment, positively contributing to the sediment budget of the marsh platform and the estuarine system. The timing of the storm surge relative to high or low tide, the duration of the surge and the presence of vegetation do not cause major changes in the sediment budget. This dataset could be used to evaluate how increased storm intensity might influence the sediment budget of estuaries in comparison to other types of coastal systems  to illustrate how the response of salt marshes to increased storm intensity varies with a change in the hydrodynamics and sediment delivery dynamics of the system. Specifications Table•The modelled storm surge scenarios can be used to evaluate how increased storm intensity might influence the sediment budget of salt marshes and estuaries.•This dataset can be used by other coastal scientists or engineers to make a comparison with other types of coastal systems (e. g. bays) to illustrate how the response of salt marshes to increased storm intensity varies with a change in the hydrodynamics and sediment delivery dynamics of the system.•Data could be used to guide an investigation into sediment delivery dynamics of real storm surges occurred in the estuary.1Scenarios of increased storm intensity modelled for the Ribble Estuary, North-West England, are presented here. Numerical simulations representing different storm surge heights were conducted using the numerical finite-difference model Delft3D 2The data was collected using the FLOW module of the numerical finite-difference model Delft3D, which computes non-steady flow and transport phenomena implementing Navier-Stokes and transport equations Natascia Pannozzo: Conceptualisation, Methodology, Data production and analysis, Data curation, Writing – original draft preparation; Nicoletta Leonardi: Conceptualisation, Methodology, Data production and analysis, Supervision, Writing – reviewing and editing; Iacopo Carnacina: methodology, supervision, Writing – reviewing & editing; Rachel Smedley: Conceptualisation, Supervision, Writing – reviewing & editing.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.