Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation.Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify operational definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors.Through a systematic review, 514 records  were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on operationalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area.Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, research, and program evaluation aimed at studying and improving RMC at the provider level. Respectful care for mothers and newborns is a right and important part of ensuring that their care is high quality and acceptable to them. Just because there is no mistreatment does not mean that Respectful Maternity Care (RMC) was given. Without a clear framework for provider behaviors that reflect RMC principles, it is hard to ensure every woman and newborn gets respectful care in practice. We compared and combined two frameworks summarizing maternal and newborn rights and came out with seven categories. Then we searched for articles that mentioned provider behaviors reflecting RMC. We found 514 articles and ended up with 54 after careful review, from which we pulled the observable behaviors for providers in each category. Almost all papers mentioned actions to protect women and newborns from harm and mistreatment, to treat them with dignity and respect, and to give information and respect choices. About half of papers mentioned actions to protect privacy and to make sure every mother and newborn gets care when needed. Only 25% of papers mentioned actions to make sure all women and newborns receive equal care, and only 15% included actions to make sure women and newborns are physically free to leave facilities at will, and get care whether or not they can pay. This framework defining RMC behaviors for providers is based on data from many studies and can be useful to look at whether maternal newborn care in facilities meets these standards and to inform training and more research to improve RMC. Maternal mortality and morbidity are widely recognized as fundamental human rights issues, and women’s right to sexual and reproductive health care—including maternity care—that is available, accessible, acceptable, and of high quality (AAAQ) is a central tenet of the technical guidance issued by the Office of the United Nations High Commissioner for Human Rights (OHCHR) on a “Human rights-based approach to reduce preventable maternal morbidity and mortality.”  MoreoverA central focus of global maternal health efforts over the last decades has been to increase the number of women giving birth within health facilities, as a mechanism to increase skilled birth attendance . As of 2Respectful Maternity Care Charter: Universal Rights of Mothers and Newborns (RMC Charter)   AND ("women"[MeSH Terms] OR "women"[All Fields]) AND ("parturition"[MeSH Terms] OR "parturition"[All Fields] OR "childbirth"[All Fields])) OR "disrespect and abuse"[All Fields]) OR (dehumanized[All Fields] AND care[All Fields])) OR (humanized[All Fields] AND care[All Fields])) OR "obstetric violence"[All Fields]) OR "respectful maternity care"[All Fields] AND ((("pregnancy"[MeSH Terms] OR "pregnancy"[All Fields]) OR ("parturition"[MeSH Terms] OR "parturition"[All Fields] OR "childbirth"[All Fields])) OR maternity[All Fields]).Our search string (limited to humans) was: A PubMed search that was conducted using this string, with no start date and an end date of May 31, 2020, yielded 466 unique records. An additional 48 relevant articles were identified from supplemental hand searches as described. Forty-seven duplicates were removed. Thus, 467 articles were screened.Two reviewers (NK and RRJ) screened titles and abstracts of all citations and two reviewers (JG and NK) reviewed the grey literature retrieved through hand search and the AMDD summaries. Articles were excluded if: (1) they lacked operationalized descriptions of RMC-related behaviors at the provider level; (2) they described the categories of mistreatment experienced by women during childbirth rather than respectful care behaviors in the affirmative; (3) they were not published in English or did not include an English translation; (4) they did not address facility-based childbirth. No exclusions were made on the basis of study design or study quality. The number of records excluded  was documented. The full text of potentially eligible articles were independently reviewed by two reviewers . Any discordance between two reviewers during both title and abstract screening and full-text review was resolved through discussion among all three reviewers.Data for qualitative synthesis were extracted from the final list of articles by two independent reviewers (RRJ and KEAS) using a standardized form developed based on the categories of RMC previously defined. From each article, the examples and descriptions of behaviors that providers can/should adopt to exemplify respectful care were identified and extracted. These data were combined, discussed, and synthesized to operationalize each category of RMC.The head-to-head comparison of the two frameworks utilized to summarize the rights of women during childbirth , 23 dispA total of 466 peer-reviewed articles were retrieved through electronic database search (Medline [via PubMed]) conducted on August 19, 2020. An additional 48 records were identified through Google Scholar, the World Health Organization website, the AMDD monthly RMC summaries from 2017 to 2020, and hand searching of bibliographies of relevant articles. After removing duplicates, we screened titles and abstracts of 467 records. At this stage, 307 records were excluded as irrelevant because they did not have an explicit mention of RMC related content. We reviewed full-text of 160 records, of which 106 were excluded for the following reasons: they did not operationalize RMC (n = 56); they focused solely on disrespect and abuse (n = 29); they were not in English (n = 18); or they focused on pregnancy care only and did not include facility-based childbirth (n = 3). The remaining 54 studies were selected for data extraction and qualitative evidence synthesis . The five behaviors that providers can perform under this theme focused on provision of appropriate care and avoidance of inappropriate practices. Providers should: (1) provide only medically-indicated, evidence-based interventions; (2) avoid harmful practices including, overuse of interventions, drugs, and technology, and unnecessary separation of the mother and baby; (3) protect clients from individual and institutional violence and mistreatment, including physical, sexual, and verbal abuse. Clinicians should provide (4) food and fluids to women in normal labor and encouragement for early breastfeeding, including skin-to-skin contact with baby, immediately postpartum, as well as (5) pharmacological and non-pharmacological pain relief options and supportive care.RMC II: Right to dignity & respect. Forty-nine out of 54 articles described behaviors to uphold the right to dignity and respect within the context of facility-based childbirth, including the importance of respect within inter-provider relationships. Important areas of RMC operationalization in this category focused on: (1) provision of culturally competent care, including respect for beliefs, traditions and culture; (2) respectful treatment of all clients, including respect for clients’ personhood, experiences, and feelings; and (3) respectful treatment of other clinicians and all other cadres of collaborating providers and staff. Further, providers should communicate effectively (4) by using language that clients can understand, and that is respectful and polite; greeting and addressing clients politely and by name; and providing verbal support and encouragement. Positive, supportive non-verbal communication to clients (5) is another important behavior exemplifying the right to dignity and respect. Finally, respect and dignity are demonstrated through sensitivity and empathy for women and partners experiencing loss and bereavement (6).RMC III: Right to information, informed consent and refusal, and respect for choices and preferences. Forty-nine out of 54 in the systematic review highlighted the importance of ensuring women are provided information and the opportunity to give informed consent or refusal, and have their choices/decisions respected. Reflecting this right, operationally, (1) providers can encourage and support women to move freely during labor and birth and assume the position of their choice; and, (2) present women with the option to experience labor and birth with the companion of their choice and to involve their significant others in their care and decisions if they desire. Further, respecting the right to information extends beyond clinical or health information to encompass information about the cost of care. Clinicians should (3) provide information to women about their care options, what to expect during labor, birth and the postpartum period; information on proposed interventions, tests, and treatments; and any out-of-pocket costs. As part of enabling of the right to information and choice, clinicians should (4) provide honest and complete information, encourage women to ask questions and express their concerns and opinions, as well as (5) engage women with decision making about their care, solicit consent for all interventions, and respect their choices including refusal of interventions.RMC IV: Right to privacy and confidentiality. A narrow majority of articles (32 out of 54) included reference to the importance of the right to (1) privacy and (2) confidentiality. Providers should keep patient information confidential and not share information unless indicated for the provision of effective care. In the synthesis, privacy and confidentiality were operationalized beyond sharing details of a medical record. Operationalizing the right to privacy and confidentiality focused on providing visual and auditory privacy to clients, including the use of drapes, screens, private room, etc., as well as limiting the number of people present to those clinically indicated or desired by the woman.RMC V: Right to non-discrimination, equality and equitable care. Far fewer articles, thirteen out of 54 records, identified the importance of non-discrimination, equality and equitable care that were focused on (1) adhering to policies on non-discrimination. Further, providers should (2) treat every client with equal respect and dignity, regardless of specific personal attributes including, but not limited to age, wealth, class, education, race or ethnicity, religion, LGBTQI + , and health or HIV status.RMC VI: Right to timely healthcare and to the highest attainable level of health. Twenty-eight records out of 54 noted the right to timely healthcare that focused on providers (1) giving prompt attention and being responsive to clients’ needs for medical care and comfort care. A critical component to operationalizing this right is (2) ensuring that every woman has a skilled birth attendant present at birth. Additionally, providers should (3) guarantee that no client is neglected or denied necessary care based on ability of pay. Finally, providers should (4) ensure continuity of care by coordinating across facilities/sites or settings and between providers.RMC VII: Right to liberty, autonomy, self-determination and freedom from coercion. Only seven articles out of 54 focused on the right to liberty and self-determination. Two key operationalized actions emerged. Providers should not illegally detain or physically restrain women or their families in the facility for any reason, including inability to pay. Second, women should never be prevented from holding, seeing, or being with their newborn for any reason, including inability to pay.RMC is a human right and a widely recognized core component of quality care , 20, 23.In the systematic review, 54 articles were identified that described objective behaviors or concrete guidance and steps to meet the seven key principles of RMC. However, most of the articles provided insights on behaviors aimed at enacting three out of the seven key principles: (1) the right to be free from harm and ill treatment; (2) the right to dignity and respect; (3) the right to information, informed consent and refusal, and respect for choices and preferences. Fewer than two-thirds of articles referenced behaviors reflecting the right to privacy and confidentiality, although lack of privacy has been found to be a barrier to facility care across numerous studies . FurtherThere are some key strengths and limitations to this analysis. To our knowledge, this is the first systematic review of provider behaviors constituting RMC; furthermore, it rests on a firm conceptual foundation provided by two highly convergent definitional frameworks enumerating key RMC principles , 23. An In proposing a codification of actionable and operational definitions for the fundamental principles of RMC based on evidence, this qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, and program evaluation aimed at studying and improving RMC at the provider level. Across diverse settings, context-specific interpretations and expressions of these provider-level behaviors may be needed to fully operationalize RMC II: the right to dignity and respect, particularly, in its aspect related to the provision of culturally competent care, including respect for beliefs, traditions and culture.For the research community, these operational functions and definitions of RMC can provide a launching point for validation as well as a common lexicon and basis for measurement and assessment of RMC. Currently, assessment of RMC has been approached using varied definitions and methods, including observation of childbirth and post-childbirth interviews with women. Potentially, this list of functional RMC actions broadens the scope for assessment and provides practical care steps to be monitored. Further, indicators built around these operationalized definitions can contribute to the assessment of effective coverage of high quality childbirth care .It is hoped that this review and synthesis will contribute toward an evidence-based foundation for provider level interventions to improve the delivery of respectful maternity care. The systematic codification, grounded in evidence, of operational definitions for RMC at the provider level should facilitate the study, design, implementation, and comparative assessment of respectful care.


Several aspects of cognition can be affected after cold exposure, but contradictory results have been reported regarding affected cognitive domains. The aim of the current systematic review was to evaluate the effects of specific cold exposure on cognitive performance in healthy subjects. A systematic search was performed using MEDLINE (through PubMed), EMBASE (Scopus) and PsycINFO databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were healthy subjects exposed to a cold environment (either simulated or not) and cognitive performance related to cold exposure with an experimental design. The literature search identified 18 studies, eight studies investigated the effect of cold air exposure and ten the effect of cold water immersion on cognitive performance of healthy subjects. There were several differences among the studies . Cold exposure induced in most of the experimental settings (15 of 18) an impairment of CP even before accidental hypothermia was established. The most investigated and affected cognitive domains were attention and processing speed, executive function, and memory. Gender differences and effects of repeated exposure and possible acclimation on cognitive performance need further studies to be confirmed. The regulation of body temperature is activated in a cold environment. The primary responses to cold comprise shivering, inhibition of sweating, and skin vasoconstriction which allow the maintenance of a normal core body temperature of 37 °C. These are regulated by nervous feedback mechanisms mediated through temperature regulating centers located in the hypothalamus, temperature receptors in the skin, and in a few specific deep tissues of the body  ,2. The hSeveral aspects of cognition can be affected even by a mild reduction in Tco  but contThe aim of the current review was to systematically evaluate effects of specific cold exposure on cognitive performance in healthy subjects, excluding those related to other confounding factors and clarifying the affected domains, since the impact of cold stress on CP can be relevant to prevent injuries or fatalities in different working categories.The systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) structured guidelines .An extensive systematic literature search on cold effects on cognition was performed by all authors using electronic databases. MEDLINE (through PubMed), EMBASE (Scopus) and PsycINFO were searched using medical subject headings (MeSH) for “cold and cognition” searched in “All Fields” up to June 2021.The online platform Rayyan  was usedThe patients, intervention, comparator, outcomes, and study design (PICOS) approach was used to specify inclusion and exclusion criteria . The incAll authors independently extracted the demographic and experimental data from the selected studies (Tables 2 and 3). When disagreement occurred, they reviewed the papers together to reach a consensus. The following data were extracted from each included study: number, gender and mean age of participants, clothes during cold exposure, environmental temperature and duration of the experimental cold exposure, subject temperature and site of measurement, timing of cognitive test (CT) administration (during or after cold exposure), CT type and the related cognitive domains, duration of the test battery, and changes in cognitive performance based on significant results. The literature search retrieved 657 (Pubmed), 1060 (Scopus), and 375 (PsycINFO) articles evaluating the effect of cold exposure on cognitive performance. A total of 68 articles were retrieved for full-text review of which 18 were selected and included based on the inclusion criteria . StudiesThe studies’ results are summarized narratively and presented in Eight studies investigated the effect of cold air exposure on CP in a climate chamber see . All parOverall results showed an impairment of CP in six of the eight studies, while CP was unaffected in two studies after acute cold exposure (ACE). CP was found to be impaired regardless of whether the tests were done in a cold environment or following cold exposure. The only study that specifically investigated both genders in two different experiments showed a partial different response . Yang etThree studies investigated CP not only after acute exposure, but also after several days of exposure (up to 10 consecutive days) ,22,24. STen studies investigated the effect of cold-water immersion on CP see . ParticiOverall results show an impairment of CP in nine of the ten studies. CP impairment was found when tests were completed both during and after water immersion. Two studies performed by the same group show partially different results for males and females ,26. SoliOnly Payne & Cheung  did not Only two studies found an improvement in CP, specifically on attention  and WM  but the The main findings of the current systematic review are that acute cold exposure induced an impairment of CP (in 15 of the 18 studies) in most of the experimental settings even in healthy subjects in a simulated setting and before accidental hypothermia was established. The most investigated and affected cognitive domains were attention and processing speed, executive function, and memory. Processing speed and executive function showed an impairment, while memory and attention showed contrasting results. Impairment of CP was observed both during exposure to cold air and cold water and persisted even after exposure and during passive re-warming. The impact of cold water exposure seems to be more pronounced than that of cold air and correlated to a clearer core body temperature drop. Though the more prevalent finding was of an impairment of CP following acute cold exposures, one single study also showed an improvement in an individual cognitive domain (attention) . There wThe majority of the studies analyzed in this review show that a single acute exposure to cold (either cold air or cold water) impairs CP  and that the extent of these effects depends mainly on individual physiological responses to cold but also on the extent of the exposure in terms of duration and Tco reached. Several discrepancies that require discussion can be observed. Given the different effect of cold air versus cold water exposure, the studies investigating CP after exposure to cold air or cold water are described separately. Overall, cold air exposure was shown to impair some cognitive domains such as attention and speed of processing ,20,23,24Three studies investigated the CP not only after acute exposure but also after repeated exposures, addressing the possible effect of cold acclimation ,22,24. SOverall, cold water immersion exposure impaired some cognitive domains such as attention ,11,28,30Only Jones et al.  exploredCold exposure results in whole-body cooling that may reduce Tco. Cooling is enhanced by exposure to cold water or wind, which both increase convective heat loss. A brief (<30 min) or intermittent exposure to cold (water immersion or air) with low thermal protection induces peripheral cooling  while a prolonged exposure induces whole body cooling with lower Tsk and Tco, thus also reducing brain temperature. Cold exposure can lower Tsk and induce mild shivering without reducing Tco which may result in cognitive distraction due to abnormal thermal sensation. Distraction caused by cold discomfort can be demanding for central attention resources and thus decrease CP. Teichner  proposedOne out of 18 studies show an improvement in one cognitive domain (attention) after ACE . The aroIt is evident from this review that several factors, such as the severity and the duration of the exposure to cold, are relevant to reduce CP. Such impairment mainly involves more complex cognitive tasks. The negative impact of cold stress on CP is relevant since different working categories  are exposed to different levels of cold and the cognitive effect of cold may result in injuries or fatalities. The findings of the current review may help to better recognize when such CP impairment may be expected and also to develop new strategies to reduce it in a gender-oriented way. Clothing for protection from the cold, tyrosine supplementation ,30 or coThe main findings of the current systematic review are that in most of the experimental settings (either cold air or cold water) cold exposure induced an impairment of CP even in healthy participants and before accidental hypothermia was established. The majority of the studies show that a single acute exposure to cold may impair attention, speed of processing, memory and executive function and these effects might depend on individual physiological responses to cold as well as the extent of the exposure in terms of duration and temperature reached. Despite the fact that data are scarce, males and females seem to have a different response to cold exposure even in CP. Repeated exposure and possible acclimation effect seems also to have an impact on CP, but further studies are needed to confirm such preliminary findings.


In response to an Australian governmental inquiry into biotoxin-related illness, the purpose of this integrative review is to bring together the current state of evidence on the prevalence, risk factors and impacts related to mould-affected housing in an Australian context, in order to inform building, housing and health research, practice and policy. The robust integrative review methodology simultaneously sought quantitative and qualitative studies and grey literature from multiple disciplines, identifying only 45 studies directly relating to Australian housing and indoor mould. Twenty-one studies highlight negative health impacts relating to indoor residential mould, with asthma, respiratory, allergy conditions and emerging health concerns for chronic multiple-symptom presentation. The majority of studies reported risk factors for indoor mould including poor housing conditions, poor-quality rental accommodation, socioeconomic circumstance, age-related housing issues and concerns for surface/interstitial condensation and building defects in newer housing. Risks for indoor mould in both older and newer housing raise concerns for the extent of the problem of indoor mould in Australia. Understanding the national prevalence of housing risks and “root cause” associated with indoor mould is not conclusive from the limited existing evidence. Synthesis of this evidence reveals a lack of coverage on: (1) national and geographical representation, (2) climatical coverage, (3) housing typologies, (4) housing defects, (5) maintenance, (6) impact from urbanisation, and (7) occupant’s behaviour. This integrative review was key in identifying emerging housing and health concerns, highlighting gaps in data and implications to be addressed by researchers, practice and policy and acts as a comprehensive holistic review process that can be applied to other countries. Indoor dampness resulting in mould-affected housing was previously estimated to affect 10–50% of dwellings in Australia, Europe, North America, India and Japan . Mould-aIn recent prevalence studies, dampness and indoor mould indicators affect up to 21% of European homes ,4, up toIndoor residential mould is the result of either singular impacts, such as weather events and flooding, or the synergistic effects of interrelated factors, multiple housing condition problems or socioeconomic situations ,21,22. TIndoor mould growth occurs when sufficient moisture is available. Prolonged exposure to moisture within a building can impact the function of insulation and increase energy use and costs , shortenIt is widely acknowledged that dampness and mould in housing negatively impact the health of the occupants . NumerouVery little attention has been given to unhealthy housing within an Australian context until recently . It appeArchitecture, building sciences and the construction industry exploring case studies and anecdotal concerns for excess condensation and mould in energy efficient housing ,42;Building physics hygrothermal risk analysis confirming concerns for the risk of indoor mould in new housing typologies ,44,45;Social sciences, public health and housing advocacy groups reporting susceptible populations at risk of poor housing conditions , housing inequality, health impacts and socioeconomic disparity ,47,48;A recent government inquiry into biotoxin-related illness reported impacts on health and economic well-being of occupants living in mould-affected housing .Despite international evidence showing that mould in housing likely relates to the synergistic effects of interrelated factors, recent Australian studies in this area appear to have been conducted in discrete disciplines while indicating emerging concerns:To compound matters, as with many other countries, COVID-19 restrictions implemented in Australia since March 2020 have resulted in more Australians spending more time at home due to government-mandated lockdowns, work-from-home requirements, home-schooling and childcare, and an increase in preferences to continue working from home after restrictions ease ,50.As a critical starting point for addressing housing, mould and health synergies, this paper aims to develop a robust integrated review methodology for this topic and bring together the current state of evidence on the prevalence, risk factors and impacts related to reported mould-affected housing conditions in an Australia context. This process helps to identify key issues and gaps in the knowledge base and to highlight future research directions in order to inform Australian building, housing and health research, practice and policy. Without a clear understanding of the current state of evidence, there is little basis for informing evidence-based policy, increasing public awareness and mitigating the occurrence of mould in Australian housing. Both the process applied in this review and the findings are of relevance to the broader international community.An integrative review method was selected for this study, as it allows for a narrative synthesis of qualitative and quantitative studies for the purpose of presenting the current state of evidence on a particular phenomenon, contributing to theory development and to help inform practice and policy. This review method allows for drawing conclusions from a range of study methodologies and sources that bridge disciplines, while ensuring rigour, quality control and replication ,52,53. TThis integrative review seeks to answer the following research question:What is the current state of evidence on the prevalence, risk factors and impacts related to mould-affected housing in Australia?Sources of the literature were restricted to the English language and studies conducted within Australia. A multiple-disciplinary literature search strategy was adopted to capture the broad nature of the research inquiry. Publications were first sourced through a search of four broad-coverage academic electronic databases , with no date restrictions, conducted in February 2020 and again in September 2021. Due to the relatively small number of papers resulting from these searches, a grey literature search was then conducted across Australian Government agencies, data archives, and policy and advocacy websites for relevant reports. A list of the grey literature website sources is shown in Search terms were initially organised into four themes: Place, Mould, Housing and Risk/Impact. The initial selection of search terms was identified following the screening of a major review paper on indoor dampness and mould by the World Health Organization (WHO) . AdditioIn general, publications were considered for inclusion if they had full-text availability, were related to original research and were published in English in peer-reviewed academic journals or conference proceedings, or by reputable organisations. Studies needed to report on indoor mould/mildew/fungi in relation to Australian dwellings  and include prevalence, risk factors or impact. Studies on both children and adults were included. A full breakdown of the study inclusion and exclusion criteria is provided in While the quality appraisal of studies included within an integrative review allows for more rigour within the study review process, there is limited consensus on the best way to approach the appraisal of multiple study types and sources of data within public health . Nor is Peer-reviewed academic literature and grey literature were assessed using the Mixed Methods Assessment Tool (MMAT) , while tDue to the nature of this review in seeking to understand the current state of evidence, all studies that met the inclusion criteria were included regardless of each study’s quality. The studies’ quality appraisal results are included in All the studies identified were initially charted into a Microsoft Excel spreadsheet with basic details, author(s), year of publication, title and database, prior to screening. Studies identified for full-text screening were saved as PDFs to an electronic file and read electronically. All included studies were saved electronically to Mendeley Reference Manager and the articles’ key findings were extracted to word summary tables.n = 1419, ScienceDirect n = 556, PubMed n = 226 and Embase n = 226). Following the removal of 1177 duplicates from the database search, 1219 records were screened by Title and Abstract, resulting in 92 articles remaining for full-text review. A further 55 grey literature studies identified via other methods were added to the full-text review. Forty-five studies ultimately met the inclusion/exclusion criteria following the full-text review. A summary list of all the included studies is provided in the This search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram illustrated in The final 45 studies selected for this review varied significantly in their study design and included 11 cohort studies (24.4%), 9 cross-sectional studies (20%), 8 prevalence studies (17.8%), 3 qualitative descriptive studies (6.7%), 3 mixed methods building industry research reviews (6.7%), 7 case studies (2 human (4.4%) and 5 housing (11.1%)), 2 mixed methods studies (4.4%), 1 interventional housing study (2.2%) and 1 governmental inquiry research summary report (2.2%). Twenty-nine studies (64.4%) were published in an academic journal or publication and 16 studies (35.6%) were obtained from other sources indicated in Five main study topics, based on study titles, emerged from the included literature, as shown by rank order in The stepped changes in building energy efficiency regulations in Australia that have focused on improvements in the thermal efficiency of the building envelope ;The cessation of mould reporting by the Australian Bureau of Statistics.The chronological distribution of all included studies is illustrated in The investigation of indoor air quality in housing and biological data in relationship to health was mainly undertaken in the mid-1990s;There are three times more studies exploring socioeconomic factors/circumstance relating to housing conditions than that of epidemiological, clinical and health studies since 2007;As building regulations moved towards more energy efficient housing and bushfire housing safety requirements, building sciences, architecture, property, law and the building/mould industry start investigating interventions, defects and “root cause” of moisture-related building issues in built environment;There is a 22-year gap in capturing or reporting indoor mould in population-based housing studies. This may indicate an incorrect assumption, until relatively recently, that enhancements in building regulations had “fixed the problem” of mould in houses (and hence the perceived lack of need to collect this data). Alternatively, it may be an indication of the consequences of the funding restrictions placed on the data collection agency .This figure clearly illustrates significant changes and trends in “who” and “how” the subject of residential indoor mould has been researched over time. Four main trends are evident: These trends highlight both a fragmented approach to studying indoor mould in Australia and considerable gaps in current health/housing biological data and housing survey data over the course of time. By contrast, recent study trends shift towards housing conditions and its relationship to socioeconomic factors and that of indoor mould interventions, defect and “root cause” studies. This shift towards housing defects and “root cause” studies, and housing conditions and socioeconomic factors is an interesting finding for both housing and building policy, and by simply implementing and reporting on regular housing condition surveys the extent of the problem of indoor mould can be better understood.2) that stretches 3860 km from north to south (latitudes 10°41′ S to 43°38′ S). This means that the climate varies greatly between climate zone 1 in the northern tropics  to that of the alpine conditions in climate Zone 8. While there is a National Construction Code, each state and territory has the legislative authority to adopt and enforce building regulations within their jurisdiction. The federal government has no jurisdiction over buildings. About 85% of the population lives within 50 km of the coastline [Australia is a federation of eight states and territories which intersect multiple climate zones. Eight broadly classified climate zones are illustrated in oastline .n = 12, 26.7%) and New South Wales (NSW) , followed by Tasmania (TAS) , Western Australia (WA) , South Australia (SA)  and Queensland (QLD) . Four studies were based in multiple states (8.8%) while only two studies (4.4%) had an unknown location. Although there are seven Australia-wide studies, the majority of studies  are located around the cooler/mild/warm temperate climates zones within TAS, VIC and NSW. Outside of the Australia-wide studies, South Australia and Queensland have limited study coverage, and the Northern Territory (NT) and the Australian Capital Territory (ACT) have no study coverage. This equates to over half (52.8%) of the landmass of Australia having none or very limited dedicated study coverage , while 3% of the landmass has the highest concentration of dedicated studies (26.7% in VIC). In addition, there is no study coverage in some of the most vulnerable climates for indoor mould being that of the tropical location of climate zone 1, and only one dedicated study in the sub-tropical location of climate zone 2.Geographically, seven studies (15.6%) were across all states and territories. The vast majority of the studies were based in Victoria (VIC)  and remote areas, which often have different housing qualities and access to different construction types, housing materials and labour expertise compared to urban/city locations, have no dedicated study coverage. As a consequence of a vast geographical expanse, Australia has an incredibly diverse range of climate zones, housing typologies, construction typologies and practices, different building regulations and different ways of living in housing. Despite this, there are a surprisingly limited number of studies exploring these vast differences in Australian housing.The main factor for mitigating dampness and mould in the indoor environment is by limiting liquid moisture and moisture as vapour, within building materials , within n = 35, 80%) was that of indoor mould/mildew/fungi and risk factors or associations for either housing conditions, socioeconomic circumstance or building characteristics. This was closely followed by the reported prevalence  of visual mould/mildew or measured fungi in housing and impacts from reported indoor mould focused on the perceived or measured health impacts . The following sections provide more insights into the included literature.As a general finding, the most common reported relationship  report indoor mould while investigating housing conditions (n = 12), or report indoor mould while investigating building characteristics (n = 18). The climatic distribution of included studies reporting housing conditions and building characteristics is illustrated in The majority of all the included studies  did not report the study locations in detail, making it impossible to ascertain their climate locations. Of these seven studies, two studies were from all states and territories, two studies were based in SA, one study was based across NSW, VIC and SA and two studies were from unknown locations. The remaining five studies were located in climate zones 5 and 6—warm/mild temperate zones.From the studies investigating housing conditions, the majority of studies  were located within either the warm and mild temperate climate zones (5 and 6) (n = 10) or the cool temperate climate zone 7 (n = 3). Four studies (22.2%) did not report the study locations in detail to infer their climate zone. Of these four studies, one study covered NSW, QLD, VIC, WA and unknown locations, one study covered VIC, TAS and NSW, one study covered NSW, QLD and VIC and one study included all states and territories. Only one of the national studies that included building characteristics included a breakdown of the results by climate zone [From the studies investigating building characteristics, the majority of the studies  for energy costs, perceived health and temperature outcomes in winter [Despite this, there are surprisingly very limited housing studies exploring real-time and longitudinal housing climate conditions, temperature, available moisture and humidity and their relationship with housing conditions, location and/or building characteristics and the occurrence of indoor mould. From the handful of studies that do capture real-time data, they are only based in the cooler climates. One study in Sydney NSW (climate zone 5/6) specifically measures the risk of mould in five freestanding houses , two stun winter . A natioHousing conditions have been mainly measured in Australian housing survey studies by using a question similar to the Australian Housing Conditions Dataset, ADA questionnaire . The houThe question does not allow for the variable “mould” in the answer?The variable is not statistically significant enough to be reported upon.The first time this question appears is in the first building characteristics, cost and condition survey capturing the data from 1994 and published in 1996, where indoor mould and its relationship with building characteristics is reported in detail . This quThe studies that did use this question (or similar) and did report mould are included in the following discussion around housing conditions. It discusses the interactions between the conditions of housing, poor housing conditions and housing tenure, socioeconomic status and exposure (longer hours of occupancy due to COVID-19). Across all the included studies, the most commonly described poor housing conditions included: visible mould or mildew on walls, ceilings and windows; absence of functional heating or cooling; rising damp; peeling paint; leaking roofs; leaking pipework and ceilings; broken amenities; structural problems; major cracks and overcrowding.n = 14,486) across a mixed tenure of private rental, public and community housing were reported as “very poor” quality housing by occupants, indicating the widespread problem of poor-quality housing in the rental market. Cracks in walls and floors (40%) was the most commonly reported problem by households, followed by indoor mould (27%), dampness (21%), and not being able to keep warm in their home during cold weather (23%).Poor housing conditions from mould, dampness, cold and cracks were reported in twelve (26.7%) of the included studies with rental properties being the most represented. Baker and Daniels  reportedn = 1547) of renters were living in a home that is in need of repairs and 35% of renters had experienced problems with mould in their bathrooms and 20% in their bedrooms. Poor-quality housing conditions continued to play a part in private rental homes that experienced leaks or flooding  [n = 116) were uninhabitable, 10% had no heating, 19% reported visible and extensive mould (majority in the bathroom), and lack of ventilation was a concern (53% of homes had one room with no ventilation and 29% had two rooms where windows were unable to be opened).The prevalence of poor housing conditions in rental households and the reporting of problems with indoor mould were supported by three further studies. One study by the advocacy group Choice et al.  reported = 1005) , with 20 = 1005)  found thn = 2.6 million households) of Australia’s housing stock. Of this 32%, 26% (n = 2.1 million households) rent from private landlords and 3.7%  rent from public social housing authorities [These findings suggest that rental properties are at a significant risk for potential problems with both poor housing conditions and indoor mould. This is a public health concern given that approximately one in three Australians rent  and Austhorities .Increased time at home due to COVID-19 factors were reported to have both protective and negative consequences with regard to mould, dampness and building cracks . On the Of the 12 studies that investigated housing conditions for indoor mould, damp and cold housing, eight studies discussed the perceived health impacts and seven studies reported a disproportional prevalence of poor-quality housing and indoor mould for those who are most socioeconomically disadvantaged.Households living in unaffordable rental situations reported mould in 39% of homes , with thHouseholds with children were also disproportionately at risk from poor-quality rental housing and indoor mould. Among households with children who rent, 39% of couples with children and 44% of single parent families reported living with three or more housing condition problems. In total, 50% of families with children in social housing reported multiple housing problems including mould and dampness ,47.n = 600) of the damp and mildew-affected homes [A similar story unfolds for households from Indigenous or refugee and asylum seeker backgrounds where cold, dampness, mould and overcrowding were commonly used to describe conditions and factors that had the greatest negative effect on occupant health ,88. A hied homes .It is widely recognised that poor housing quality and poorly maintained housing are risk factors for dampness and mould and damp housing conditions increase the risk of asthma related to allergens, mould and house dust mites ,105,106.The prevalence of asthma in Australia is surprisingly one of the highest in the world  with 1 iBuilding characteristics and risk factors for indoor mould in the Australian context are illustrated in Two different pictures emerge within the included studies for building characteristics and risk of indoor mould. Older homes with data collected prior to 2003 include age-related conditions such as: age of home greater than 40 years, poor housing conditions, cracks in cladding, water-damaged floorboards, roof leaks, water intrusion and carpets older than 5 years. Older housing typologies such as housing with stumps, double brick or brick veneer walls, inadequate ventilation or air movement, limited insulation, lack of kitchen or bathroom exhausts and cold rooms were also at risk from indoor mould.By contrast, the majority of the studies capturing housing data after 2003 report a shift in risk to that of the use of air-conditioning, building leakage  attributed to construction defects and concerns for surface/interstitial condensation in code-compliant houses, apartments and units.The risk of mould in split-system air-conditioning units occurs due to a lack of maintenance, while the risk of mould in a room or wall cavity occurs due to temperature differences between a conditioned room and an unconditioned room or space. Latent conditions of hidden mould reside in areas related to building defects, such as failed waterproofing or problems with gutters that affect the wall, roof or floor cavities but are not visible for detection until the problem has been occurring for a long period of time ,92. In aUnderstanding the national prevalence of contemporary building characteristic risks and the “root cause” associated with indoor mould is not conclusive from the limited geographical and climatical coverage of the included studies.Considering the critical role an occupant plays in managing ventilation, thermal comfort, condensation, cleaning, household maintenance and the risk of indoor mould, this topic is surprisingly understudied in Australia. The majority of the included studies (75%) discussing the relationship between occupant behaviours and the risk of indoor mould are based on older housing typology (20 years old or more) and were collected before the introduction of newer housing built to energy efficiency standards. However, the role the occupant plays in managing indoor mould, housing ventilation and cleanliness was the most reported relationship that both increases and reduces the risk of mould in housing, illustrated in Past experiences from older occupants having grown up sleeping on enclosed verandas or “sleep-outs” influenced current protective behaviour measures to keep windows or doors permanently open to avoid the risk of mould and improve breathing in newer homes . Lack ofRecent studies report a reluctance to open windows due to energy costs and a lack of occupant awareness of their behaviours and role in reducing condensation . More ren = 22) (48.9%) and is illustrated in The prevalence of mould/mildew/fungi-affected dwellings was reported in approximately half of the included studies  had mould or mildew. A more recent study by Baker et al. [The only national cross-sectional, population-based housing survey that reported indoor mould conditions for all housing tenures was conducted in 1994. This study by the ABS  reportedr et al.  capturinReporting comparable data in future academic and grey literature is strongly recommended for: the year(s) when the housing data is collected, tenure, housing type, age of the property, housing typology and other critical information, for example, climate zone, location, building characteristics, and if the property had undertaken renovations, repairs or maintenance, especially for moisture-related problems. This would conceivably provide more meaningful insights for policy decisions when investigating the prevalence, root cause and risk of indoor mould in relation to the building envelope design, housing typology and housing and building regulatory provisions. Longitudinal studies  are recommended to help identify the impact of home renovation and maintenance activities and monitor housing conditions.Although the current evidence is inconclusive to establish a full geographical, climatical and typological representation and comparable study methods, the results suggest that the prevalence of mould/mildew/fungi continues to be an unresolved problem in Australia housing.n = 12, 26.7%) supporting a causal relationship with mould/mildew/fungal indicators and asthma, wheeze, cough, respiratory and clinical associations of domestic allergic alveolitis and hypersensitivity pneumonitis. Reported relationships between mould/mildew/fungal indicators and health effects are illustrated in Internationally, there has been considerable research undertaken in the area of respiratory health, allergies and respiratory infections following exposure to dampness and mould . SimilarSeven of the included studies (15.6%) reported allergy, atopy, gastrointestinal, mood, depression and pain in relation to indoor mould/mildew/fungal indicators. While allergies in children  and an iThe remaining five studies (11.1%) reported a mixed variety of symptoms similar to that of Sick Building Syndrome (SBS) and overlapping environmental illness conditions in relation to indoor mould. The earliest report in Australia of SBS-type symptoms in relation to indoor mould was reported by Robertson  in the eEmerging anecdotal evidence from the included studies reports that perceived health effects related to living in housing with dampness or visible mould extend beyond previously well-studied health associations to that of changes in mood, sadness, depression ,87, painIndividuals responding to the Australian Government’s inquiry into biotoxin-related illness  reportedThe purpose of this review was to bring together the full range of research on the prevalence, risk factors and impacts related to mould-affected housing in an Australian context in order to disseminate the findings and identify research gaps and implications for building, housing and health research, practice and policy.This review highlights a general lack of geographical and climatical coverage, especially for warmer tropical/sub-tropical areas and regional locations. This is compounded by the sheer size of the country, a lack of national housing survey data and lack of consistency in the type of data collected and by a fragmented approach to how mould-affected housing has been studied over time. Notwithstanding these coverage limitations, synthesis of the evidence reveals that indoor mould in Australian housing exists in a complex interrelated and interdependent system of risk factors between the built environment , occupant behaviours , socioeconomic factors , household structure  and implications of regulatory provision and protection policy .These findings support previous observations in energy-related risk factors for indoor mould  and recoFuture research would benefit from adding two additional broad-risk categories for indoor mould that have been overlooked or observed in Australia. Firstly, for countries with significant travel distances or housing located in regional or remote locations, extending the eighth category of risk for “Urbanisation” to include “Regionalisation”. Secondly, introducing a ninth risk category called “Policy” for nations who have experienced a national increase in the time spent at home or are in the process of developing energy efficient housing regulations or making significant changes to building typologies.Implement national and climatical coverage of real-time data  and “root cause” case study investigations for indoor mould in both older housing and code-compliant homes.Investigate the relationship between occupant behaviours, housing maintenance and the occurrence of indoor mould in poor-quality housing.Establish a national longitudinal housing condition survey that includes indoor mould, renovations and maintenance.To continue to use the question “Does this dwelling have any MAJOR building problems?” or similar in current longitudinal housing studies and report on the “mould” variable.Investigate the impact and characteristics of multiple-symptom health effects and their relationship to the biological components that are present in damp housing conditions.Further to the discussion, we highlight a need for future work to address the following research and practice needs:With uncertainty around the cause, extent and prevalence of indoor mould in code-compliant housing, this study suggests that building regulatory authorities adopt the precautionary principle before moving forward with any future changes to housing energy efficiency provisions that have the potential to increase the risk of surface/interstitial condensation or indoor mould.“The precautionary principle, proposed as a new guideline in environmental decision making, has four central components: taking preventive action in the face of uncertainty; shifting the burden of proof to the proponents of an activity; exploring a wide range of alternatives to possibly harmful actions; and increasing public participation in decision making.”This is the first study to use an integrative review methodology to collate and unpack the current state of evidence on the prevalence, risk and impact from indoor mould in Australian housing. This comprehensive holistic review process can be replicated in other countries.This study reports that the perceived emerging health effects following exposure to dampness and mould extends beyond accepted health associations such as respiratory symptoms, asthma and infections to that of a chronic multiple-symptom presentation. Our scientific understanding of these multiple-symptom health effects is limited globally and, within an Australian context, is unknown. Evidence on the extent, the prevalence of indoor mould and the relationship between building characteristics and the risk of mould is not conclusive on a national level for all residential dwelling types. This is because of a general lack of geographical and climatical coverage.Like other countries, Australia has experienced significant changes over the last 20 years in housing and building policy regulations, the adoption of energy efficient housing provisions, a shift towards building apartments and an increase in single dwelling housing production in addition to a change in how occupants use their home. So as to provide healthier housing, future research into mould-affected housing is critically important to support regulatory decisions, especially since Australia experiences climate vulnerability, extreme weather events and sees a shift towards a greater number of Australians spending more time at home.


According to the scoring exercise, 10 assessments  were suitable without modification for informal markets. Suitability for formal markets was markedly higher, with 41 assessments  found suitable without modification. Experts considered availability, accessibility, price, and affordability the most important dimensions of market food environments to evaluate in LMICs. Market-basket analysis and vendor audits (which include inventories) were ranked as the most suitable methods to assess multiple dimensions of market food environments, including availability, price, affordability, vendor and product characteristics, marketing, and regulation. Gaps in relevant assessments were found for convenience and desirability. Results demonstrate the need for the development, adaptation, and validation of assessments relevant for informal markets in a diverse range of LMIC contexts to support diets, nutrition, and health globally.Globalization is transforming food environments in low- and middle-income countries (LMICs) with implications for diets and nutrition. However, most food-environment assessments were developed for use in high-income countries. We evaluated the suitability of 113 data-collection assessments  for eight dimensions of informal and formal market food environments for diverse contexts of LMICs. We used a scoring exercise and a survey of experts ( Food environments in low- and middle-income countries (LMICs) are changing, spurred by the globalization of food systems  and the Within the food system, the food environment is the nexus between food supply and demand and is increasingly recognized as a primary driver of dietary patterns ,14,15,16Multiple researchers have proposed frameworks to characterize food environments in LMICs ,14,15,20Despite advances in the development of data-collection assessments  to evaluate food environments over the past 20 years , most asAlthough recent frameworks ,16,21 deThe widely accepted Turner et al., (2018) framework  was chosThe research team conducted a literature search using the key term “food environment” to compile a list of existing data-collection assessments defined as either a method, tool, or metric for evaluating the food environment. The PubMed, Agricola, USAID Development Experience Clearinghouse (for papers on market information systems [MISs]), Google Scholar, and Web of Science databases were searched. The inclusion criteria were: (1) a focus on market food environments; (2) available in English; and (3) published after 1998. The team then used a snowballing approach of referencing additional articles from citations in the identified articles, including recently published reviews on food-environment assessments ,15,16,24The assessments were categorized as either a method, tool, or metric (See n = 11) followed by vendor and product characteristics (n = 9) and convenience (n = 7). For tools, availability had the most (n = 15) followed by vendor and product characteristics (n = 8) and accessibility (n = 7). For metrics, price had the largest number (n = 7) followed by affordability (n = 6).Categorizing the data-collection assessments by the external and personal domains of the Turner et al., (2018) food-environment framework resulted in a list of 74 assessments to evaluate the external domain and 39 assessments to evaluate the personal domain, with several assessments assigned to more than one food-environment dimension (Each of the four research team members scored the categorized list of data-collection assessments and accompanying descriptions for suitability in LMICs in: (1) informal market settings, (2) formal market settings, and (3) both informal and formal market settings. Scores of 0 (indicating not appropriate or would require major modification), 1 (could be appropriate with minor modification), or 2 (appropriate as is) were assigned to each assessment. For example, food-environment assessments developed in a high-income country and focused on attributes of supermarkets such as shelf placement were scored as 0 for use in an informal market setting, 2 for use in a formal market setting, and 0 for both informal and formal settings. Given that food vendors may be mobile and/or not listed in directories, assessments that examined density of food vendors were assigned a score of 1 for use in an informal market setting, 2 for use in a formal market setting, and 1 for both informal and formal settings. Assessments developed, piloted, and validated in rural and urban LMIC contexts were scored as 2.The scores from each research team participant were compiled and averaged to develop Suitability Scores for informal market settings, formal market settings, and combined informal and formal market settings. The standard deviation of participant scores was calculated to evaluate variation in scoring as a measure of inter-rater reliability; discrepancies greater than 0.5 points were discussed as a team. All assessments that received an average Suitability Score of 1.5 or greater for combined informal and formal markets were determined to be suitable for use in LMIC contexts, either in the current form or with minor modification.Assessments that received Suitability Scores of 1.5 or greater were included in a survey instrument sent to global experts with experience working in LMICs. The survey consisted of 20 questions grouped in four parts . The surThe survey consisted of four parts: (1) informed consent; (2) background information on expert’s area of work, food-environment dimensions generally measured, and food-environment dimensions perceived as most important; (3) practices and perceptions concerning food-environment methods, including characteristics for deciding if a specific food-environment assessment is suitable in LMICs; and (4) practices and perceptions regarding food-environment tools and metrics. Experts were requested to rate the suitability of methods for evaluating market food environments in rural areas  in LMICs as “not suitable,” “somewhat suitable,” and “very suitable”  availability and accessibility; (2) marketing, vendor and product characteristics, convenience, and desirability; or (3) prices and/or affordability.Survey data were analyzed for frequency of responses. Importance Scores were calculated by averaging the weighted rankings of the importance of each of the eight dimensions of the food-environment framework for understanding rural contexts in LMICs for influencing diets and nutrition. The responses were equally weighted based on the ranking order given by the experts. Two sets of Importance Scores were calculated; the first set was based on the experts’ ranking of the food-environment dimensions in their own practice  of the 113 assessments were determined to be suitable with minor or no modification  for informal market food environments as well as collectively for informal and formal market food environments in LMICs . NotablyFor methods, price was the food-environment dimension with the highest Suitability Score (1.63) for both informal and formal markets, whereas desirability was the dimension in the personal domain with the highest Suitability Score (2.0). Vendor and product characteristics had the highest Suitability Score for tools (0.81) and metrics (1.32) in the external domain of the food environment. Affordability was the food-environment dimension in the personal domain with the highest Suitability Score for tools (1.04), and accessibility had the highest Suitability Score for metrics (1.75).The food-environment dimensions in the external domain with the most assessments rated as suitable without modification for use in both informal and formal markets were availability for methods (three methods) and vendor and product characteristics for both tools and metrics (one tool and one metric). The food-environment dimensions with the most personal domain assessments rated as suitable without modification for use in both informal and formal markets were desirability for methods (two methods) with no suitable tools or metrics.When asked the type of food environment they most commonly assess, experts responded informal market (78%), formal market (63%), cultivated (56%), and wild (33%) food environment. When asked about the most commonly measured dimensions, responses were availability (89%) price (74%), desirability (74%), vendor and product characteristics (67%), accessibility (67%), convenience (63%), and sustainability (52%).Experts perceived availability , accessibility , affordability , and price  as the dimensions most important for understanding rural contexts in LMICs for influencing diets and nutrition. When considering a program perspective, the Importance Score order (from highest to lowest) differed from that of the experts’ personal perspective as follows: availability (7.77), price (7.0), affordability (6.82), and accessibility (6.78) .The surveyed experts identified a range of characteristics they value when identifying suitable food-environment assessments for LMICs. The characteristics reported by 50% or more of the experts include : (1) the assessment captures multiple dimensions of the food environment (95%); (2) culturally relevant (91%); (3) context specific (77%); (4) appropriate for diverse types of food environments (68%); (5) easy to implement (68%); (6) results in findings that are translational (64%); (7) cost-effective (64%); (8) validated (59%); and (9) rapid (50%). The following characteristics were reported by less than half of the surveyed experts for identifying suitable food-environment assessments for LMICs: (1) the assessment is objective (45%) and (2) scalable (23%).Several of the surveyed experts reported tools and metrics for evaluating food environments that were not in the survey; the most prevalent of these was the Market Diversity Index. This metric was not included in the survey because it was under review for peer-reviewed publications when we conducted our search for assessments to include in the scoring exercise and survey. From experts’ responses, key themes of what is needed to enhance food-environment assessments in LMICs emerged. These included ensuring food-environment assessments suitable for LMICs are available and developing guidance protocols, best practices, and training on suitable assessments.Findings highlight the need for modification of existing assessments and the development of new assessments for evaluating dimensions of the informal market food environment in LMICs. The suitability scoring found notably more assessments as suitable without modification for formal market food environments than for informal market food environments. Availability, accessibility, price, and affordability were considered by the global experts surveyed as the most important dimensions of market food environments to evaluate in LMICs. Market-basket analysis and vendor audits (including inventories) were the most suitable methods to assess the food-environment dimensions of availability, price, vendor and product characteristics, marketing and regulation, and affordability. Consumer surveys  were ranThe assessments identified as suitable for evaluating each food-environment dimension have varying levels of data, resource, and skill requirements. A method may be deemed suitable while needing to be developed into a data-collection tool or metric specific for informal and formal markets in LMICs. Many methods lack a corresponding tool including consumer surveys/interviews, vendor audits, mapping, market-basket analysis, and photo-elicitation. The development of relevant tools and metrics from available methods is one of the main assessment needs we identified.The scoring exercise found low suitability of assessments for use in informal market food environments in LMICs, especially for convenience and desirability, and points to a need for adaptation of existing assessments or development of new ones. For example, the Nutrition Environment Measurement for Stores was developed for a USA context with food items benchmarked based on American diets . Other aSurvey findings that availability, accessibility, price, and affordability were the most important dimensions of market food environments to evaluate in LMICs correspond with the recent literature. Specifically, the food-environment frameworks of Herforth and Ahmed (2015), HLPE (2017), Turner et al., (2018), and Downs et al., (2020) all include the dimensions of availability and/or accessibility as well as price and/or affordability. However, the Herforth and Ahmed (2015) and Downs et al., (2020) frameworks only include the external domain of the food environment; they do not view the personal domain as part of the food environment but rather the way individuals interact with the food environment. The finding that availability is the most important dimension of market food environments to evaluate in LMICs is further aligned to the finding that multiple methods were found suitable for this dimension.Market-basket analysis and vendor audits, the two methods found most suitable to assess multiple food-environment dimensions in LMICs, are suitable because they can be modified for observing different types of market food environments and a range of food groups appropriate for LMICs. Research and development are needed to modify existing audits to include culturally relevant food groups  as well as other characteristics, such as vendor types. Other suitable food-environment methods for LMICs include market mapping , SeasonaDespite MISs receiving the highest Feasibility Score for evaluating availability, shortcomings of this assessment for use in informal market settings were noted. These included access to technology and secondary data, such as national price data on various foods, as well as questionable relevance of national price data for diverse contexts within an LMIC. In addition, an MIS may be characterized as a method with metrics, such as Cost of Healthy Diets, being a specific type of MIS.MFDI was not included in the survey, because the peer-reviewed paper about this metric was not published at the start of this study. However, some experts surveyed noted it as a suitable metric, and it is increasingly being implemented in LMICs. Thus, MFDI is included by our research team as a recommended metric to evaluate market food environments in LMICs see . MFDI haAn adapted version of the HEI of Food Supply is included by our research team as a recommended metric to evaluate the availability of foods that are aligned to quantitative FBDGs in market food environments in LMICs, based on the Feasibility Score from the survey responses see . The HeaVendor audit and market-basket analysis, the methods rated as very suitable for measuring food price and affordability, are the basis of several metrics including Cost of a Healthy Diet   that recVendor audits, the method rated as very suitable for measuring vendor and product properties and marketing and regulation, is the basis of the EPOCH tool, which had the highest Feasibility Scores for these food-environment dimensions. The EPOCH instrument was designed to be suitable in diverse cultural, socioeconomic, and regional  settings across different communities, regions, and countries. The inter-rater reliability of EPOCH was validated in 93 rural and urban communities in five countries  and demonstrated excellent reliability . The EPOGaps to be addressed by additional development of tools and metrics were found for the personal food-environment dimensions of convenience, accessibility, and desirability. Previous studies  found a Although most experts evaluated consumer surveys as suitable for measuring the personal domain, the limited tools and metrics that exist need adaptation. For example, the ProDes tool was developed and validated for rural and urban contexts in the United States based on a market basket of fruit and vegetables listed in the Nutrition Environment Measurement Survey for Stores . For adaFindings of the lack of tools and metrics for several dimensions of the personal domain of the food environment are aligned with the discrepancy in food-environment frameworks regarding whether the personal domain is part of the food environment or rather comprises the ways individuals interact with the food environment. Regardless of the place of the personal domain, it is critical to understand the dimensions of the personal domain because these notably influence healthy diets, nutrition, and health. The overall gaps identified in available data-collection tools and metrics for the personal domain of food environments are supported by previous research with similar findings. For example, the recent review by Toure et al., (2021) highlighted that gaps remain in the completeness of available assessments for dimensions of the personal domain of the food environment, including desirability and convenience.Given the low to moderate Suitability Scores from the scoring exercise and Feasibility Scores from the survey of experts, adaptation of existing assessments and development of new assessments should consider multiple attributes valued highly by the surveyed experts including that an assessment: (1) captures multiple dimensions of the food environment; (2) is context specific; (3) is appropriate for diverse types of food environments; (4) is easy to implement; yields findings that are translational; (5) is cost-effective; (6) is validated; and (7) is rapid. Tool and metric adaptations and developments should be pilot tested in diverse LMIC contexts to ensure suitability before wider deployment. Given the need for culturally relevant assessments for informal markets and limitations of rural settings in LMICs, future work can draw from fields that have a history of rural field research  and can focus on assessments that are practical and feasible for the context. To enable and enhance the routine monitoring and evaluation of multiple food-environment dimensions, such assessments should be accompanied by guidance protocols, best practices, training materials, and data analysis templates for implementing that are free, user friendly, and centrally available with clear guidance on how to interpret and synthesize findings.For the food-environment dimensions for which a lack of suitable tools and metrics was found, the methods identified as suitable should be used as the basis to develop tools and metrics for relevance in informal markets. Importantly, assessments scored as not suitable without major modification for informal markets have potential for use in LMICs if major modifications are conducted. For example, the Retail Food-Environment Index (RFEI) , which cAlthough this study focused on market food environments, we recognize that wild and cultivated food environments are also important for supporting food security and nutrition in LMICs ,41 and iIn addition, while sustainability received a relatively low valuation by the experts for measurement in LMICs compared with all the other dimensions of food environments, sustainability is a critical attribute of food systems to support long-term food security ,45,46 A The development and implementation of data-collection tools and metrics that assess the sustainability of foods in the food environment, such as the Sustainability Properties of Food in the Food-Environment Rating tool , can supBuilding healthy food environments and ensuring consumers have access to healthy foods are essential steps towards realizing multiple targets outlined in the United Nations Sustainable Development Goals (SDGs) . AdvanciAs primary drivers of diets, food environments are critical to understand for improving diet, nutrition, and health outcomes globally. Monitoring and evaluating market food environments in LMICs is especially critical given the increase in foods purchased from markets, diets higher in ultra-processed foods and added sugar and salt, and the associated upsurge of comorbidities that threaten human and economic development . However


We investigated the ancestral origins of four Ecuadorian ethnic groups—Afro-Ecuadorian, Mestizo, Montubio, and the Indigenous Tsáchila—in an effort to gain insight on the relationship between ancestry, culture, and the formation of ethnic identities in Latin America. The observed patterns of genetic ancestry are largely concordant with ethnic identities and historical records of conquest and colonization in Ecuador. Nevertheless, a number of exceptional findings highlight the complex relationship between genetic ancestry and ethnicity in Ecuador. Afro-Ecuadorians show far less African ancestry, and the highest levels of Native American ancestry, seen for any Afro-descendant population in the Americas. Mestizos in Ecuador show high levels of Native American ancestry, with substantially less European ancestry, despite the relatively low Indigenous population in the country. The recently recognized Montubio ethnic group is highly admixed, with substantial contributions from all three continental ancestries. The Tsáchila show two distinct ancestry subgroups, with most individuals showing almost exclusively Native American ancestry and a smaller group showing a Mestizo characteristic pattern. Considered together with historical data and sociological studies, our results indicate the extent to which ancestry and culture interact, often in unexpected ways, to shape ethnic identity in Ecuador. We investigated the ancestral origins of four Ecuadorian ethnic groups—Afro-Ecuadorian, Mestizo, Montubio, and the Indigenous Tsáchila—to gain insight on the relationship between genetic ancestry, culture, and ethnic identity in Latin America. Our results highlight the different ways in which ancestry and culture interact to shape identity in Ecuador. High levels of Spanish ancestry were almost always associated with higher social status. The related concept of mestizaje refers to the underlying process of racial and cultural mixing, also with an implicit preference for Spanish ancestry and culture.15Nation building in colonial-era Latin America was explicitly aware of, and informed by, notions of race and ancestry. An emphasis was placed on the delineation of new racial (ethnic) groups formed by various combinations of the three continental ancestry groups that came together in the New World: African, European, and Native American. This movement reached its apogee with the Spanish mestizaje played out in a very particular way, whereby the initial ancestry-based definition of Mestizo slowly gave way to a more culture-based definition that was tied to language, education, and social status. Given the conflation of ancestry, culture, and social status with ethnicity in Ecuador, the ancestral origins and makeup of different ethnic groups have been obscured. Genetic studies, considered in the context of this unique history, can shed light on the extent to which ancestry does or does not contribute to Ecuadorians’ ethnic identities. Indeed, there is a growing interest among Ecuadorians to better understand the ancestral composition of these socially constructed ethnic groups, particularly with respect to historically marginalized Indigenous and African identities.18In Ecuador, the process of ,,Previous studies have characterized the genetic origins of the different ethnic groups in Ecuador,Afroecautoriano), Indigenous (translated from the Spanish Indigena), Blanco, Mestizo, and Montubio.,afrodescendiente), which is widely used in Latin America to refer to the descendants of African people who arrived in the Americas via the trafficking of enslaved persons during the colonial era.The terminology used to describe the populations studied here is intended to distinguish ethnicity from genetic ancestry. For ethnicity, we use the names of the officially recognized Ecuadorian ethnic groups following the 2010 census: Afro-Ecuadorian (translated from the Spanish DNA samples were characterized for 300 sample donors from four Ecuadorian ethnic groups across seven locations: Afro-Ecuadorian (91), Mestizo (35), Montubio (82), and Tsáchila (92). Afro-Ecuadorian samples were taken in the city of Esmeraldas in Esmeraldas province and in the Chota Valley, located between provinces of Imbabura and Carchi. Montubio samples were taken in the cities of Portoviejo, Jipijapa, and Chone in the Manabí province. Mestizo samples were taken in Quito, Pichincha. Tsáchila samples were taken in Santo Domingo de los Colorados of the province of Santo Domingo de los Tsáchilas. Blood samples were obtained from donors by the finger-prick method and collected on FTA cards . Donors provided demographic information for themselves, their parents, and their grandparents: surnames, place of birth, place of residence, ethnic self-identity, and spoken language. The same technician was responsible for collecting all donor blood samples and demographic information. Donor blood samples and demographic data were collected in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. All samples were provided voluntarily, de-identified, and securely archived. All donors approved and signed the Informed Consent Form , and donDNA was extracted from FTA card blood spots using QIAGEN’s DNeasy Blood & Tissue Kits. Genome-wide genotyping was performed for 22 Mestizo samples using the Multi-Ethnic Global ArrayFor characterizing global and local continental ancestry, the Ecuadorian genome-wide genotype data were merged and harmonized with whole genome sequence data from global reference populations representing four continental population groups—African, East Asian, European, and Native American—characterized as part of the 1000 Genomes Project,The final continental ancestry variant dataset was further harmonized with two additional reference panels for characterizing subcontinental ancestry. We separately merged the final variant dataset with (1) 1,235 African genomes across 37 additional African reference populations,K = 4. Admixture entropy values are measured as the Shannon’s entropy Principal component analysis (PCA) of the final continental ancestry dataset was performed using PLINK using the “-pca” option, and the first two PCs for all samples were plotted using the ggplot2 package,A modified version of RFMixThe RFMix ancestry assignments were used to generate masked genomes, each of which only contain haplotypes from one of the three main continental ancestry groups, for subsequent subcontinental ancestry inference using either the program Chromopainter version 2Subcontinental ancestry inference validation was performed by generating simulated admixed genomes via Monte Carlo simulation of reference population haplotypes. For the simulation of admixed genomes, reference populations were divided into training and validation samples. Training samples were used to simulate admixed genomes, and validation samples were used for subcontinental ancestry inference on the simulated admixed genomes. Simulated admixed genomes were generated using genome-wide haplotype boundaries, defined using interpolated genetic map positions based on the 1000 Genomes Project, and haplotypes were randomly selected from reference population training samples across 20%–80% admixture proportions in 5% increments, generating 20 simulated genomes for each 5% increment. For sets of simulated admixed genomes, the simulated (expected) ancestry proportions were compared to the observed ancestry proportions inferred via the NNLS approach, using Pearson correlation, to estimate the accuracy of the NNLS method for subcontinental ancestry inference. Simulated admixed genomes were generated and validated in this way for African subcontinental ancestry inference  and European subcontinental ancestry inference .K ranging from 2–12. Cross-validation error values were calculated for each value of K and used to select the optimal value of K = 10 for subsequent analysis. Native American subcontinental ancestry was characterized using ADMIXTURE, because haplotypes in Native American populations are quite distinct, owing to very high levels of population structure among these populations,ST values with smartpca from the EIGENSOFT package version 7.2.1.ST values were used to make a neighbor-joining treeSubcontinental ancestry for Native American populations was discerned using Native American masked genomes with the Native American-harmonized dataset using ADMIXTURE run in unsupervised mode, with values of ,The TRACTS program,ΔAdmix) is defined as:andSex bias in admixture for the different Ecuadorian population groups was inferred by comparing the ancestral composition of the X chromosome to the autosomes as previously described.Individuals from four Ecuadorian ethnic groups were sampled from seven sites around the country: Afro-Ecuadorian from Esmereldas and the Chota Valley, Mestizo from Quito, Montubio from Manabí, and Tsáchila from Santo Domingo de los Colorados A. GenomeThe program ADMIXTURE was used to quantify the levels of continental ancestry—African, East Asian, European, and Native American—for the four Ecuadorian populations compared to other admixed American populations . On averContinental ancestry was inferred at the local level by assigning genome-wide haplotype origins corresponding to the three major ancestry components of the Ecuadorian populations—African, European, and Native American—using a modified version of the program RFMix.The chromosomal distributions of ancestry-specific haplotypes can also be used to evaluate sex-biased patterns of continental admixture. Since X chromosomes spend twice as much time along the female lineage, compared to autosomes, excess continental ancestry on the X chromosome indicates female-biased admixture, whereas excess continental ancestry on the autosomes points to male-biased admixture. We previously developed the ΔAdmix parameter, which quantifies differences in ancestry between the X chromosome and the autosomes, to test for sex-biased ancestry in admixed American populations.Ancestry-specific haplotypes were leveraged to perform fine-scale, subcontinental ancestry inference for the Ecuadorian samples, with separate analyses run for each of the three continental ancestry components. To do so, continental ancestry-specific genomes were generated by masking haplotypes that correspond to two of the three continental ancestry components. This process yielded three masked genomes per sample: an African-haplotype-only genome, a European-haplotype-only genome, and a Native American-haplotype-only genome. Each ancestry-specific genome was then compared against corresponding reference populations from Africa, Europe, and the Americas to explore the subcontinental ancestral origins for the Ecuadorian ethnic groups.African subcontinental ancestry for the Ecuadorian ethnic groups, along with other admixed American populations, was characterized using a panel of 42 African reference populations, 37 of which were sampled from six of the seven main western African regions involved in the transatlantic slave trade.The African reference populations from these regions show distinct patterns of ancestry, with coherent patterns of ancestry seen for West African and West Central African populations and diverse ancestry seen for the Bantu-speaking populations of Southwest Africa . The obsThe Ecuadorian groups show varied patterns of African ancestry, with affinities to different admixed American populations . The Afr2 = 0.99; We validated our approach to African subcontinental ancestry inference using simulation of admixed genomes containing different combinations of ancestry for the four main African regions analyzed here. Simulated genomes were generated for a range of ancestry fractions (20%–80%) for each of the four African regions, and our subcontinental ancestry inference approach was applied to the simulated admixed genomes. Ancestry inferences for all four of the main African regions show high levels of accuracy when region-specific simulated (expected) ancestry values are compared to observed values generated via the subcontinental ancestry inference approach used here (Rth century.2 = 0.96).All four Ecuadorian populations show a pattern of European ancestry that is mostly consistent with Spanish ancestry, similar to what is seen for other modern Latin American populations from Colombia, Mexico, Peru, and Puerto Rico . While tGiven the complex demographic history of Indigenous populations in the Americas, and the high levels of population structure seen for Native American ancestry reference populations, we were not able to directly quantify Native American admixture proportions for the Ecuadorian populations in the same way that was done for their African and European ancestry components. Native American ancestry in the Ecuadorian populations was analyzed via ADMIXTURE, to get a qualitative view of their ancestry composition, and with phylogenetic analysis to infer the most closely related reference populations. The Native American origins of the Ecuadorian ethnic groups were characterized using a panel of 23 reference populations from Mesoamerican, Central American, Colombian, Amazonian, and Andean tribes , in compADMIXTURE showed an optimal number of K = 10 ancestry components , and theulations .Figure 5mestizaje and assimilation.A major aim of this study was to consider Ecuadorian ethnic identity in the context of the genetic ancestry and origins of the people that make up the country’s officially recognized ethnic groups. An emphasis was placed on previously understudied and historically marginalized groups, including Afro-Ecuadorian, Montubio, and Tsáchila populations. The genetic ancestry of the majority Mestizo ethnic group was considered in light of historical knowledge on Ecuadorian population dynamics and the cultural forces related to ,,Contrary to our expectations, Afro-Ecuadorians did not show a large majority of African ancestry, although it was the single largest ancestry component on average 49.5%; , and the24,,The Mestizo ethnic group shows an average of 66.1% Native American ancestry, which is higher than any other admixed American population studied here except for Peru. As with the Afro-Ecuadorians, there are a number of individuals who identify as Mestizo but have almost entirely Native American ancestry  and 2. Amestizaje, and have remained largely unchanged over centuries. Some scholars have claimed that Montubios are essentially another Mestizo group, with respect to mixed Spanish and Native American ancestry, albeit with a distinct cultural heritage.The complex relationship between ethnic identity and ancestry in Ecuador is exemplified by the newly recognized Montubio ethnic group. Montubios live primarily in the coastal region of Ecuador—in the provinces of Manabí, Guayas, Los Rios, and El Oro—and their cultural identity is tied to a distinctly rural and agrarian lifestyle. Given their recent origins and recognition, this group stands out as a counterexample to the narrative that ethnic identities in Latin America were formed in the early colonial period, via the process of Our results highlight the admixed nature of the Montubio population. The main ancestry component is Native American, followed closely by European ancestry, with a smaller but not insubstantial African component  and 2. MOverall, the Tsáchila show a very high level of Native American ancestry 87.1%; . HoweverThe Tsáchila individuals studied here were sampled from the city of Santo Domingo de los Colorados located in the province of Santo Domingo de los Tsáchilas, which, as the name suggests, is the historical homeland of the group. Even the name of the city “de los Colorados” (of the dyed) refers to the Tsáchila ethnic group and their custom of covering themselves in the red juices of achiote seeds to prevent smallpox infection. Thus, it may be the case that residents of Santo Domingo de los Colorados with Spanish and Native American ancestry, who may be expected to ethnically identify as Mestizo, identify as Tsáchila. This would be an interesting example of individuals from a relatively high-status majority group choosing to identify with a historically oppressed Indigenous group. On the other hand, Tsáchila ethnic identity may provide social advantages for Mestizo individuals who reside in their Indigenous homeland. The distinction between ancestry and ethnic identity among the Tsáchila Santo Domingo de los Colorados also suggests the possibility that ethnic identity in Ecuador is strongly influenced by local geographic origins and culture.The results reported here show how genetic ancestry co-varies with ethnicity in Ecuador: Mestizos and Montubios are primarily admixed with Spanish and Native American ancestry, whereas the Tsáchila and the Afro-Ecuadorians show the highest levels of Native American and African ancestry, respectively. All four ethnic groups show evidence of sex-biased admixture with greater levels of male European and female Native American ancestry, consistent with the historical record. Nonetheless, we find the exceptions to these general trends to be the most interesting and revealing findings. We observed several unexpected patterns of genetic ancestry for different ethnic groups, which underscore the extent to which ethnic identity in Ecuador is shaped by both culture and ancestry. Mestizos show surprisingly high levels of Native American ancestry, when considered together with the size of the Indigenous population in the country, pointing to the role of language and cultural assimilation in the formation of this ethnic group. The Afro-Ecuadorians show the lowest levels of African ancestry, and the highest levels of Native American ancestry, seen for any Afro-descendant population in the Americas. This population includes a number of individuals with almost entirely Native American ancestry, pointing to the possibility of a distinctly African cultural identity for the region, shaped by its unique history.