Antimicrobial resistance (AMR) poses a global threat to human, animal, and environmental health. AMR is a technical area in the Global Health Security Agenda initiative which uses the Joint External Evaluation tool to evaluate national AMR containment capacity. This paper describes four promising practices for strengthening national antimicrobial resistance containment capacity based on the experiences of the US Agency for International Development’s Medicines, Technologies, and Pharmaceutical Services Program work with 13 countries to implement their national action plans on AMR in the areas of multisectoral coordination, infection prevention and control, and antimicrobial stewardship.We use the World Health Organization (WHO) Benchmarks on International Health Regulations Capacities (2019) to guide national, subnational, and facility actions that advance Joint External Evaluation capacity levels from 1 (no capacity) to 5 (sustainable capacity). Our technical approach is based on scoping visits, baseline Joint External Evaluation scores, benchmarks tool guidance, and country resources and priorities.implement appropriate actions using the WHO benchmarks tool, which prioritizes actions, making it easier for countries to incrementally increase their Joint External Evaluation capacity from level 1 to 5; (2) integrate AMR into national and global agendas. Ongoing agendas and programs at international, regional, and national levels provide opportunities to mainstream and interlink AMR containment efforts; (3) improve governance through multisectoral coordination on AMR. Strengthening multisectoral bodies’ and their technical working groups’ governance improved functioning, which led to better engagement with animal/agricultural sectors and a more coordinated COVID-19 pandemic response; and (4) mobilize and diversify funding for AMR containment. Long-term funding from diversified funding streams is vital for advancing and sustaining countries’ Joint External Evaluation capacities.We gleaned four promising practices to achieve AMR containment objectives: (1) The Global Health Security Agenda work has provided practical support to countries to frame and conduct AMR containment actions in terms of pandemic preparedness and health security. The WHO benchmarks tool that Global Health Security Agenda uses serves as a standardized organizing framework to prioritize capacity-appropriate AMR containment actions and transfer skills to help operationalize national action plans on AMR. E. coli isolates had a high resistance percentage for recommended first- and second-line antibiotics [Antimicrobial resistance (AMR) continues to pose a global threat to humans, animals, and the environment, with dire consequences for the global economy and health security if it remains unchecked . The mosibiotics .E. coli [E. coli isolates from various human, animal, and environmental sources in the 13 target countries described in this paper (12 in Africa and 1 in Asia—see Table Extended-spectrum β-lactamase (ESBL) production is a major mechanism for multidrug resistance in E. coli . Table 1A number of factors contribute to less effective AMR control in LMICs, such as poorer sanitation and hygiene ; limitedAs of November 2022, 170 World Health Organization (WHO) member states had finalized their national action plans on AMR (NAP-AMR) , which mSince September 2018, the mandate of the US Agency for International Development’s Medicines, Technologies, and Pharmaceutical Services (MTaPS) program  has been to work with 13 countries  tool (2018)  and WHO Table The JEEs provide valuable baseline status of countries’ national capacities in various technical areas but moving from evaluations to capacity-strengthening actions has been difficult. The 2019 WHO benchmarks tool complements the JEE tool and provides an organized framework with capacity-level appropriate actions for incremental progress in the JEE technical areas. Our program is one of the first mechanisms to use the tool as a principal guide in its GHSA support for AMR containment.We made scoping visits to 11 of the 13 collaborating countries. Our program in Mozambique and Nigeria started in October 2020 during the height of the COVID-19 pandemic, so the initial information on these two countries was based mainly on document reviews and long-distance consultations. Our scoping exercises determined that most collaborating countries had finalized their NAP-AMR, but their operationalization was weak, and many had not drafted costed implementation plans. Mechanisms for multisectoral coordination on AMR existed in some form, but countries struggled with functionality and needed help with establishing and/or strengthening their technical working groups (such as those for IPC and AMS). In IPC, policies and guidelines mostly existed but needed support with updating, implementing, and monitoring. Most countries lacked antimicrobial consumption and use data as well as AMS policies, guidelines, and programs, which required elementary support; for example, several countries, including Mali and DRC, had no oversight structure for drug and therapeutics committees, and although Côte d’Ivoire had a collection of AMS guidelines, there was no one national policy or set of guidelines.We supported capacity improvement in the 13 countries in 3 of the 4 AMR containment indicators included in the 2018 version of the JEE tool—MSC on AMR (P.3.1); IPC (P.3.3); and optimizing the use of antimicrobial medicines in human and animal health and agriculture through AMS (P.3.4)  and the transfer of competencies through training-of-trainers and cascade training and onsite skills-building support; creating centers of excellence; and improving the capacity of national, subnational, and facility governance entities, professional associations, and civil society organizations. We strategically collaborate with government counterparts and other implementing partners in the self-propagation and scale-up of evidence-based tools, techniques, and approaches.The program fosters vertical coordination between national- and facility-level stakeholders and horizontal coordination between facilities through peer mentorship and cross-fertilization. Supportive supervision and mentoring are a collaborative effort among national stakeholders and program staff using pre-agreed checklists. The aim of this support is to strengthen the local capacity to achieve and maintain best practices in IPC and AMS for the long term.Listed below are the key activities the program supports in the three technical areas.Strengthening leadership and governance functions or technical capacity of the multisectoral  coordination body on AMR Helping to set up or improve the functioning of national technical working groups on IPC and AMSSupporting the development and update of IPC, AMS, and MSC governance documentsFacilitating collaboration between the human and animal health sectors and seeking opportunities to also engage the environmental sectorHelping to revise countries’ NAP-AMR and develop a monitoring and evaluation framework and operational/implementation plan for countries’ NAP-AMREvaluating IPC programs and practices in facilities using the WHO IPC assessment framework (IPCAF)  and natiConducting more specific facility assessments of compliance with IPC guidelines by using the WHO hand hygiene self-assessment framework and adapted WHO IPC scorecardsSupporting facility-level health care-associated infection point prevalence surveys and the design and implementation of health care-associated infection surveillanceHelping to develop or update IPC guidelines, standard operating procedures, and action plans at the national and facility levelsHelping to establish and make functional national IPC committees or technical working groups and facility IPC committeesIncorporating quality improvement approaches for facilities to identify, address, and monitor IPC issuesBuilding capacity in IPC competencies in facility staff and other categories of health care personnel through training, eLearning, mentoring, and supportive supervisionConducting rapid assessments of country laws, regulations, and guidelines related to AMS and antimicrobial supply chainsConducting facility AMS assessments to inform actions based on WHO-recommended AMS core elements Capacitating government counterparts to use WHO standardized methods and tools, such as the Anatomical Therapeutic Chemical (ATC) and defined daily doses (DDD) methodology and point-prevalence survey , to condIncorporating the WHO AWaRe  classification of antibiotics , 52 in pPromoting the creation and function of national AMS committees or technical working groupsSupporting the development of AMS documents such as policies, guidelines, and plansSupporting the establishment and strengthening of facility drug and therapeutics committees to provide AMS-related oversightDeveloping facility AMS action plans and helping to determine priority areasStrengthening AMS training and including practical AMS topics in pre-service curricula and in-service trainingAs indicated, WHO developed most of the tools used. Some were adapted in partnership with national stakeholders for local country contexts and needs before implementation. For example, several countries adapted IPCAT2 or IPCAF tools to assess IPC programs related to animal health and agriculture, and in Bangladesh, COVID-19 elements were incorporated into standardized IPC assessments. To ensure quality results in the assessments, country stakeholders met to review and validate the drafts before finalizing.A GHSA 2024 Framework strategic objective  is to imSince 2018, our work with the 13 countries, guided by the WHO JEE and benchmarks tools, points to four promising practices for countries to strengthen AMR containment  process  and recuThe IPC benchmark actions emphasize repeat IPC assessments to measure incremental progress due to iterative interventions . WHO proThe WHO benchmarks tool recommends actions around monitoring antimicrobial consumption and/or use in each of the capacity levels 2 to 5. Without access to reliable data on AMR and antimicrobial consumption and use, it is difficult to establish and run an AMS program and to carry out other AMS benchmark actions to increase JEE capacity. It is therefore critical to build the capacity of government counterparts to conduct and interpret studies that characterize national antimicrobial consumption and/or facility antimicrobial use as in the case of DRC, Tanzania, and Uganda Table . At the The WHO benchmarks tool recommends integrating AWaRe categories of antibiotics into national governance documents such as national essential medicines lists and standard treatment guidelines. DRC, Kenya, Mali, and Tanzania incorporated AWaRe categories in such documents using a checklist the program developed . By instInstitutionalizing the monitoring of IPC and AMS practices is an important benchmark to achieve JEE level 5—sustainable capacity. The Uganda Ministry of Health instituted a standardized IPC supportive supervision checklist, while the Senegal Ministry of Health integrated IPC into its standard supportive supervision tool and staff training. The ministry of health in Tanzania incorporated AMS into its nationwide Afya Supportive Supervision program and added IPC indicators to those collected in the DHIS2, thus ensuring that facilities routinely collect and report IPC data as part of a systems-strengthening approach. The Uganda Ministry of Health sent a circular to health facilities’ leadership that approved and recommended appropriate medicine use and monitoring activities, including point prevalence surveys to support AMS.Ongoing agendas and programs at international, regional, and national levels provide opportunities to mainstream and interlink AMR containment efforts . SeveralWe helped to establish or guide IPC and AMS technical working groups in 9 countries and AMR secretariats in 11 countries to prioritize, plan, and review activities. Through this work, we found that reinforcing governance in MSC bodies and their technical working groups—for example, by improving terms of reference, membership diversity, vertical coordination, and meeting frequency—enhances their functionality . We workThe human health sector in our 13 collaborating countries tends to be more active in AMR containment compared to the animal health, fisheries, or environment sectors, and MSC meetings are typically led by the ministry of health. However, our work with MSC bodies and working groups using the GHSA lens has improved animal sector engagement, providing impetus for involving the environmental sector. In Mozambique, for example, we brokered consensus between human health and animal health representatives to rotate responsibilities for running the MSC mechanism on AMR and its technical working groups. From a practical standpoint, inspired by the WHO IPC assessment tools for the human health sector, and without similar tools for IPC assessment in the animal sector, Côte d’Ivoire, DRC, and Mali adapted IPCAT2 and/or IPCAF to conduct IPC assessments in the animal sector. Mali conducted its first national-level IPC assessment in the animal health sector using a modified IPCAT2, which led to the development of IPC guidelines and an action plan. A hygiene and IPC rapid assessment was done in 10 veterinary practices, 8 slaughterhouses, and 33 poultry farms in Côte d’Ivoire using tools adapted from IPCAF. Burkina Faso developed its first national guidelines for using antibiotics in the animal sector, and in Uganda, the program coordinated the development of the first veterinary essential medicines list and five guidelines on infection prevention and use of antimicrobials in food-producing animals. Coordination between national counterparts in both the human and animal sectors produced these achievements.COVID-19 has highlighted how systems-based and institutionalized MSC and IPC initiatives can strengthen pandemic preparedness and contribute to rapid responses. Our prior work to strengthen governance in MSC and IPC helped national stakeholders respond more quickly to COVID-19 in several ways . For exaMany of the countries that we support rely primarily on donor funding for their national AMR program, and the MSC bodies and their technical working groups tend to be inadequately funded. Major outbreaks often cause a temporary surge in political commitment and budget allocations, but countries generally struggle with advancing and sustaining their JEE capacities because of insufficient resources and competing national priorities . TherefoAMR is an invisible threat, which impedes its ascendence as a national priority. GHSA and IHR provide a health security perspective by framing the issue in terms of outbreak prevention and preparedness. This perspective can complement national AMR containment efforts, and it is important to integrate AMR with other national-level GHSA technical areas. Fields such as immunization, zoonotic diseases, and food safety are integral for reducing the burden of infectious diseases and antibiotic consumption. As such, national AMR programs and immunization programs should work closely with each other to promote proven vaccines to reduce infections and need for antibiotics . Robust Linking AMR containment to global and national health priorities such as UHC and the Sustainable Development Goals can leverage synergies ; in factGHSA, JEE, and IHR have substantially advanced MSC, which has been hailed as a paradigm shift toward One Health . The 2ndWhile donor funding can be vital in initiating AMR-related activities, the WHO benchmarks tool highlights the integral role of financing with recommended actions related to funding mobilization and diversification , and susWhile the 2019 WHO benchmarks tool provided a useful set of recommended capacity-appropriate actions based on JEE 2, we also noted some limitations while helping implement the tool in the collaborating countries. A key observation was that several AMR-related actions had two or more components requiring different streams of efforts and stakeholders combined within a single action, such as including both animal and human health-related work in AMS and IPC areas and developing AMS plans and legislation. Additionally, some of the IPC actions recommend the use of several tools in the same action, making it hard to demonstrate progress based on partial or selected use of the tools. Importantly, while the tool recommends human and animal sector actions, it does not mention any specific environmental sector-related actions within the AMR technical area. Also, neither JEE 2 nor the 2019 benchmarks tool links IPC actions to pandemic preparedness capacity. JEE 3 has addressed some of these limitations and now separates human and animal actions for AMS and mentions the role of IPC in outbreaks and pandemics.WHO has declared that AMR is one of the top 10 public health threats the world faces [Country stakeholders and partners must move beyond just assessments and recommendations and start implementing locally feasible AMR containment actions. Our experience shows that regular, locally led follow-up is needed after initial assessments to prioritize and implement interventions, as are repeat assessments using the same tools to demonstrate evidence-based improvements, such as those seen through repeated IPCAT2 and IPCAF assessments in several of our partner countries. The WHO benchmarks tool is valuable to help countries prioritize such actions based on existing capacities to incrementally improve their JEE capacity through multisectoral governance and other efforts. Although the tool is primarily designed for use in conjunction with JEEs to support GHSA and IHR, it could potentially be used more broadly to simplify and prioritize NAP-AMR implementation actions.The path to sustaining best IPC, AMS, and surveillance practices and multisectoral coordination under One Health requires a health systems strengthening approach that builds on locally existing systemic foundations and capacities; lasting transfer of skills in the use of proven tools, technologies, and methodologies; and country ownership and institutionalization of initiatives. In this manner, national stakeholders, donors, and partners will continue to help countries move toward achieving demonstrated (level 4) capacity or a comparable level in several technical areas in the coming years, thereby contributing to GHSA .In this paper, we presented four promising practices highlighted through our 13-country collaboration experience and discussed country examples that could potentially be scaled. As LMICs continue to tackle the growing threat of AMR using the WHO benchmarks and other tools, sharing lessons learned and best practices and highlighting critical gaps will continually improve the technical resources available to strengthen their AMR containment capacity.


Tooth decay remains the most prevalent chronic disease in children and adults, even though it is largely preventable. Studies show that mothers’ oral and overall health is linked to children’s oral health and pregnancy outcomes. This paper examines achievements during the last 20 years, assesses current challenges, and discusses future priorities.Data show a modest improvement in children’s oral health during the last 20 years; however, tooth decay still affects more than half of adolescents. According to national survey data, about 26% of working-age adults had untreated tooth decay. Overall, significant oral health disparities by race/ethnicity and income persist.The annual dental visit rate for children in the 2015 Medical Expenditure Panel Survey was 48%. Among children enrolled in Medicaid, dental visit rates increased from 18% in 1993 to nearly 50% in 2018. About 46% of women are estimated to receive teeth cleaning during pregnancy. Over the years, race or ethnicity and income-level differences in dental visits observed in the early 2000s have narrowed substantially in children but not among pregnant women.Many effective interventions are available at the community and individual levels but are underutilized. Lack of integration of oral health into the overall health care system and programs, community conditions, poverty, and limited health literacy make it difficult for families to engage in healthy habits, use preventive interventions, and access treatment promptly.To further improve oral health, policy and system reforms are needed to address the factors mentioned above. Therefore, we urge the federal Maternal and Child Health Bureau to take steps to convene a workshop to develop a framework for future actions. What is already known on this subject? Existing publications discuss the extent to which women, children, and adolescents experience oral health problems, effective policies and programs, and the need to integrate oral health care into the overall health care system.What does this study add? This manuscript provides a historical perspective on efforts and progress made to address the causes of high oral disease rates, unmet oral health treatment needs, and profound oral health disparities. It also discusses challenges that four major programs have encountered in working to achieve better oral health outcomes. In addition, it makes recommendations for improving oral health and calls for a national workshop to develop a framework for future actions. During World War II, one of the primary reasons for rejection of army recruits was failure to meet the minimum standard of having at least 12 teeth Allen, . Today, As early as the 1920s, the Maternal and Child Health (MCH) Section of the American Public Health Association (APHA) recognized the importance of oral health to overall health by including “dental hygiene” in its efforts to detect and correct health defects in children  decreased by about 56%, from 7.1 in 1971–1974 to 3.1 in 1986–1987  among Mexican American adolescents  tooth decay, untreated tooth decay, and mean DMFT among women with teeth aged 20–64 years, as reported by the 2011–2016 National Health and Nutrition Examination Survey (NHANES), were 92%, 24%, and 9.6, respectively. There were no noticeable gender-specific differences  was 48%  teeth. According to the 2011–2016 NHANES, nearly half of children aged 9–11 years (51%) and adolescents aged 12–19 years (48%) had dental sealants on permanent teeth, reflecting an increase of more than 10% points since 1999–2004  2019 self-reported dental visit data, about 46% of respondents reported having their teeth cleaned during pregnancy  estimates that each year about 1 in 1,564 babies are born with cleft lip and cleft palate; another 1 in 2,807 babies are born with a cleft lip; and 1 in 1,687 are born with a cleft palate  is the most common sexually transmitted infection in the United States. According to the CDC, each year about 14,800 new cases of oropharynx cancer are caused by human papillomavirus (HPV)  timeline that provides a historical perspective of significant events in the United States , the Partnership for Integrating Oral Health Care into Primary Care, and the Networks for Oral Health Integration Within the Maternal and Child Health Safety Net.Advances toward improving oral health care for the MCH population have reduced untreated tooth decay by nearly 50% in young children and resulted in unprecedented dental coverage for pregnant women by all state Medicaid programs  has proposed changes to the Title V Maternal and Child Health Services Block Grant to States Program guidance for the next 5-year (2025–2030) period. One proposed change is to transition the oral health NPM to a state performance measure (SPM).Oral health has been an NPM since 1997. If oral health is transitioned to an SPM, it will no longer be viewed as a national priority, and efforts to promote oral health care at the federal, state, and local levels will suffer. Therefore, the oral health NPM needs to be retained to highlight the profound disparities in unmet needs and stimulate oral-health-related activities at the state and local levels  report  is the controlled adjustment of the natural fluoride (F) concentration in community water supplies in the U.S. to the concentration of 0.7 mg/L F to prevent tooth decay.  benefit. Increasing dental coverage and use of dental services by children enrolled in Medicaid and CHIP has been a major strategy for improving the oral health of children over the past 25 years, especially those at highest risk for oral diseases. Dental services for children must minimally include relief of pain and infections, restoration of teeth and maintenance of dental health. A referral to a dentist by his or her primary care provider is also required for every child in accordance with the periodicity schedule set by each state and at other intervals as medically necessary. The design and administration of Medicaid and CHIP dental benefits are highly dependent on programs organized by state agencies.Dental care for adult Medicaid beneficiaries is an optional benefit for state Medicaid programs, with coverage ranging from no benefits in a few states to relatively extensive coverage in many states. With respect to the focus of this paper, most states offer more comprehensive dental benefits to the pregnant population than the general adult population and provide coverage to higher household income levels (Center for Medicaid CHIP Services & Division of Quality and Health Outcomes, In 2011, the CMS identified several barriers to using dental services (Department of Health and Human Services, Growth of these programs has substantially increased public dental benefits coverage for children to the point that in 2017 Medicaid and CHIP covered 39% of American children younger than age 19, with coverage by state ranging between 25% in Wyoming and 56% in New Mexico (Brooks et al., Oral Health in America: Advances and Challenges concluded that research increasingly shows that poor oral health during pregnancy is linked to adverse health outcomes for mothers and babies (National Institutes of Health, The 2021 Transforming existing programs and care delivery systems to achieve more optimal outcomes will require a multidimensional approach focusing on communities, patients, providers, and policymakers. Recommended actions include conducting educational campaigns to increase public awareness and knowledge of the importance of dental care during pregnancy, improving health professionals’ education and training regarding the importance and safety of providing oral health care to pregnant women, systems improvements to foster better integration of oral health services across diverse types of health care providers and settings, and assuring dental benefits coverage throughout these critical periods (National Institutes of Health, Oral Health Care During Pregnancy: A National Consensus Statement, to highlight recommended services and required policy and system-level changes (Oral Health Care During Pregnancy Expert Workgroup, The groundwork outlining what can and should be done to promote oral health during pregnancy, postpartum and early childhood has already been established. In 2011, HRSA issued a landmark publication, Crall and Vujicic have identified achievements and ongoing challenges in improving children’s oral health and offered a range of corresponding solutions Table . These iAt the national level, Healthy People 2030 focuses on reducing tooth decay and other oral health conditions and helping people get oral health care (Office of Disease Prevention and Health Promotion, In addition to the focus on dental services in traditional settings, the Community Preventive Services Task Force recommends CWF and school-based programs to deliver dental sealants based on strong evidence of their effectiveness in reducing tooth decay (Community Preventive Services Task Force, Oral Health in America: Advances and Challenges identified three broad-ranging concepts influencing oral health and disease outcomes (National Institutes of Health,


Transgender and nonbinary (TGNB) adolescents and young adults are underrepresented in the literature on eating disorders and body image-related problems, despite increased mental health disparities and emerging research showing high associations between gender dysphoria, body image, and eating disorders among TGNB youth.The scoping review was designed to critically examine the research on TGNB adolescents and young adults who experience eating and body image related problems as well as clinical studies on treatment approaches and effectiveness.Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this scoping review. The electronic databases of MEDLINE and PsychInfo were used for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for transgender minor children, adolescents, or young adult samples (18 to 25 years old) and address differences in eating/body-related problems by age. The relevant data was extracted and narratively summarized.49 studies were identified, data extracted, and analyzed. Increased prevalence of eating disorders and body image problems were identified for TGNB youth. Body-gender congruence through gender affirming social and medical interventions  were noted as significant for alleviating body image problems and facilitating eating disorder treatment. Family and social factors were not well understood in the literature and a need for increased study of TGNB youth from varied racial/ethnic, neurodiverse, and within specific identities  and families and cultural contexts is still needed.Future research should consider the use of developmental and family theories for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, more studies are needed with those from minoritized racial and ethnic groups, neurodiversity, and varied gender identities  for identifying important differences. Forty-nine published research studies with transgender and nonbinary (TGNB) adolescents and young adults on eating patterns and body image were identified, summarized, and critically examined. Eating disorders and body image problems are more prevalent with TGNB adolescents and young adults, as compared to their non-transgender peers. More research is needed TGNB minor children, adolescents, and young adults as separate groups and as part of family and social settings where they may experience rejection and delays in seeking and accessing treatment. Adolescence and emerging adulthood  are marked by both increased autonomy, development of a sense of self, reliance on peers , and incTGNB youth experience minority stressors during critical periods of development. Minority Stress Theory (MST) was originally created to explain the health disparities of gay, lesbian, and bisexual adults , and hasMST also identifies several protective factors: social and family acceptance, support for a gender affirmation through social changes , access to gender affirming medical treatments  , 11, andIn this scoping review, MST was utilized as a framework for identifying significant factors contributing to outcomes for varied ages and differently marginalized subgroups . MST provides a critical lens for the review analysis including types of methods employed, the language used in describing TGNB youth, and the treatment approach and outcomes of TGNB youth. External stressors are experienced across family, school, and healthcare settings for TGNB youth. Thus, MST guides this review to reflexively consider what factors are being considered for TGNB youth that may differ from TGNB adults or other groups experiencing eating disorder and body image problems.MST posits that TGNB youth health outcomes will vary based on external and internal stressors, which are further influenced by mental health comorbidities, age, family and social acceptance, racial/ethnic context, and access to gender affirming healthcare and treatment. MST offers a lens for examining the literature on TGNB youth with disordered eating and body image related problems. This scoping review aimed to answer four research questions: (1) What methodologies are being used to study eating and body image related problems among TGNB youth? (2) What are the risks and protective factors for eating and body image related problems for TGNB youth? (3) Who is being included and excluded in the TGNB youth samples of studies on eating and body image related problems? (4) What are the empirically supported treatments for eating and body image problems for TGNB youth? The focus of this paper is youth only. TGNB adult literature is detailed in another scoping review .Current literature reviews on TGNB youth and eating disorders span broad sexual and gender minority populations and ages , 17 or pThis scoping literature review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines in the search, review, and reporting processes  and inclMEDLINE, PsychINFO, CINAHL: Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systemic Reviews, Social work Abstracts, Social Services Abstracts, and Sociological Abstracts to identify potential articles about transgender adults and eating, body, and weight related problems. The second author (WL) was consulted based on her expertise in nutrition and dietetics to review initial searches for relevant articles.The search strategy was developed through initial meetings and consultation between the first author and the university librarian  in the fall of 2020. Preliminary searches were conducted using the OVID interface of possible databases including MEDLINE and PsychINFO—were superior for identifying relevant articles. To search the databases, we identified official search terms  in the databases through the OVID interface  published in peer review journals (including online advance publications); (2) published in English language by December 2022; (3) described qualitative or quantitative empirical research (including case reports and case studies); (4) sample of transgender youth ; and (5) addressed review questions about eating behavior and body image including those addressing treatment and intervention. “Youth” was defined as minor child to adolescent (< 18 years old) and emerging adulthood (18 to 25 years old). Given the critical period of development cognitively, identity formation, and risks for mental and physical health among young adults under the age of 25, we elected to include these emerging adults in the youth subpopulation . TGNB adThe following types of studies were excluded from the review: book chapters; review articles; editorial commentaries; clinical opinion articles without case or research data; non-English language studies; dissertations; studies where outcomes from transgender participant data were not reported separately from the larger sample; studies that did not include at least one of the following—eating behavior or disorder measurement, body image scale, interview data on eating or body image.n = 136) were removed initially by the software. This was reviewed by the first author to ensure accuracy of the removal. Reviews were completed by three research team members  and four undergraduate and graduate research assistants. Pairs of authors and research assistants reviewed abstracts based on the inclusion/exclusion criteria. Discrepancies in the reviews were resolved by the first and second authors. Then, full text reviews were completed by the second and third authors and the research assistants. Again, discrepancies were resolved by the first and second authors. Data extraction was completed by the second, third, and fourth authors. Finally, one case control study article was removed at data extraction as two reviewers  agreed that the study did not meet our inclusion criteria as transgender people were the subject of the work, but not the participants in the study [The identified articles were uploaded to Covidence©, an online software, for managing duplication removal and then the process of abstract review, full text review, and, finally, data extraction. Duplications  and adult (adult-only samples) tables for separate analysis. Then study methodology  was analyzed by the first and third authors identifying and quantifying types of methodology, sample size and demographics, measurement use, and geographic location. We also to identify limitations inherent in current methodologies for drawing meaningful conclusions. Variable outcomes  were analyzed by the second and fourth authors. The results were then narratively summarized. Variable outcomes were reported based on divergent and consistent findings across studies. In addition, unique findings were noted for subsamples, if appropriate.Finally, overarching bias and limitations in the studies were summarized. To assess rigor and potential bias in studies, the authors used four items from the STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE) checklist  and the n = 36 studies), while the remaining studies covered body image, body satisfaction, and body-gender congruence. Finally, one study with minor youth aimed to develop a scale for eating disorders with TGNB youth [The review yielded 49 articles  by a variety of funding sources including federal and internal university funding. Only 12 studies included discussion of theory or a guiding theory. Of the studies that did include theory, six referenced minority stress theory [A review of bias and limitations across studies showed 12 studies lacked limitations sections and 13 studies were missing acknowledgments of potential biases in the study. About half of the studies were funded  and the SCOFF (n = 3 studies). Other eating disorder scales used include the Adolescent Binge Eating Disorder Questionnaire, Nine-item Avoidant/Restrictive Food Intake Disorder Scale, Stanford-Washington University Eating Disorder Screen, Eating Pathology Symptoms Inventory, and Motivations to Eat Scale. Body image scales varied widely across studies and is discussed further in the body image section of the results. Finally, the Transgender Congruence Scale was used in two studies [A total of 28 quantitative studies were identified. All articles retained for this study employed a cross-sectional study design. Body image alone was studied in eight articles with mostly young adult samples. Eating disorders alone were studied across 19 samples with minor youth and young adult samples. The remaining two studies measured both body image and eating disorder variables. Several different measures were used to assess the variables of interest. The most common were Eating Disorder Examination . The samples were drawn from two primary sources: clinical samples (n = 12) or college or high school student surveys (n = 8). Finally, most of the quantitative studies included primarily racially White samples, while six included large racially diverse populations with between 50 and 70% white participants [Most of the studies originated from within the United States  detailing one to five individual cases of gender dysphoria, eating disorders, body image and dissatisfaction, and body size using a mix of qualitative and quantitative data. The findings from these case reports focused on transgender patients and their outcomes of gender affirming medical treatment [Within the articles retained for the literature review, 22 utilized a qualitative or case study approach. Most were case studies  or medically  , 61–63, n = 5), the severity of symptoms of depression and suicidality were exacerbated by delay in seeking treatment for gender dysphoria. Ristori et al. [Prevalence of eating disorders in studies utilizing medical records identified comorbidities of eating and mental health disorders   and gendi et al.  utilizedi et al. , utilizei et al. , and inci et al. . Finallyi et al. .Studies analyzing only young adults largely sampled college students in the United States. These studies found that TGNB young adults were more likely to engage in disordered eating, purging, and use of diet or laxative pills than their cisgender peers ; and, mun = 84) differed in the degree to which they saw their disordered eating as connected to body image. Some saw clear connections where eating patterns used to change their body’s shape or size to fit a gendered ideal, while others did not see a connection [In one qualitative study, a large sample of TGNB young adults  as perception and feelings about one’s own physical body . In qualitative interviews, body dissatisfaction was shaped by gender dissociation, dissatisfaction with body size, and their intersections [Body image was generally defined in studies  compared to those who received less treatment or no treatment at all . Five caThe aims of the scoping review were to critically analyze all known published literature on disordered eating and body image with TGNB youth (including minor children and young adults). The review covered areas of risk and protective factors for eating disorders and body image, who is represented in the study samples, methodologies employed in the literature, and treatment modalities and associated factors. In addition, we noted bias and limitations across studies inclusive of language and its limits. The increased prevalence of eating disorders and body image related problems among TGNB youth, especially young adults, is well established through large, representative surveys with insights about causes, risks, and protective factors in case reports and qualitative interviews , 45, 47.Common mental health comorbidities for minor TGNB children included anxiety , whereasThus, understanding the etiology, prevention, and treatment of eating disorders and body image problems of TGNB youth requires inclusion of family as key factors and points of interventions . Future Many of the studies lacked diversity in other dimensions of identity or context, especially in the minor children and adolescent studies. In particular, this review noted a lack of racial and ethnic diversity in some samples, only one study exclusively focused on non-binary or gender queer individuals, and one article describing the treatment of a TGNB youth with autism spectrum disorder . This maFrom 2018–2022, 57% of the studies in this literature review were published (n = 28 studies) suggesting empirical research continues to increase for TGNB youth. Recent studies are exploring differences between transgender  and non-binary or gender queer youth where non-binary/gender queer youth may not have the same heightened risk of poor body image when they see themselves outside of stereotypical social expectations and gender norms . Though There is an inherent limitation to estimating eating disorder and disordered eating prevalence in that only one instrument has been tested for use with TGNB youth at this time . TGNB yoThis review has several limitations. The team carefully planned and utilized software to accurately answer the study questions and conduct the review. However, research studies may have been missed. The current studies still lack nuance by variations in gender identity, developmental age, expression, race, neurodiversity, and social factors. Limiting the search to English means other international studies were missed. Some of the studies included transgender and non-transgender samples, requiring reliance on portions of the data or only descriptive analysis. Many of the studies were cross-sectional in nature, limiting causal associations between risk factors, treatments, and outcomes documented in the studies. Finally, the rigor could have been enhanced by pre-registering our search protocol with the International Prospective Register of Systemic Reviews.The scoping review offers an overview and critical examination of research with TGNB youth who experience eating and body image related problems as well as clinical studies on treatment approaches and effectiveness. The 49 studies identified demonstrated the prevalence of eating disorder and body image related problems for TGNB youth as compared to their peers. Future research should intersectional approaches to treatment that allow for increased racial/ethnic diversity, the co-occurrence of neurodiversity , and family and social factors influencing eating patterns, body image, mental health, and treatment outcomes.


This paper presents a framework and toolkit for assessment of multi-hazard livelihood security and resilience in the Lower Mekong Basin (LMB) communities. The LMB is a subsidiary region of the Mekong region in South East Asia, and is frequently exposed to hydrometeorological hazards and anthropogenic stressors that expose and directly affect the livelihoods of more than sixty-five million people living in the region. The main purpose of the study is to support decision-making and risk management planning through integration of the concepts of livelihood security and resilience into a holistic framework, and subsequently developing an index-based toolkit for conducting assessments. Firstly, dimensions, sub-dimensions and indicators for measurement of livelihood security and resilience in the LMB were identified through comprehensive literature review and expert consultation. Then, several local workshops were conducted with various stakeholders  in the LMB region to validate the indicators and generate weightages. The indicators were then arranged in a matriculated form, and the weightages were used to generate the algorithm for computing the quantitative outputs of livelihood security and resilience in study area. An Excel toolkit and a ‘R’ programming package were developed using the algorithm for visualization of the assessment outcomes. The proposed framework and toolkit are expected to assist researchers, government officials and development professionals in generating robust resilience assessment indices for risk informed decision-making and planning.Brief outline of the method•Livelihood security and resilience concepts were integrated to generate a holistic assessment framework and an indicator library.•Weightages for indicators were generated using the Analytical Hierarchical Process (AHP) through consultation with relevant stakeholders.•The indicator library was developed into an algorithm-based Excel and ‘R’ programming toolkit that provides quantitative assessment outputs.  Specifications tableThe Lower Mekong Basin (LMB) is a subsidiary region of the Mekong River, with approximately sixty-five million people directly dependent on the river for livelihood and economic activities . HoweverIn the first phase, a comprehensive literature review was done to develop the indicator library for the LiSeRA tool to measure the multi-hazards perspectives of the selected communities in LMB countries . Following the development of the indicator library, capacity-building training workshops were conducted in the project countries for the stakeholder perspectives to define weightage and ranking for the indicators through Analytical Hierarchical Process (AHP). Finally, the resilience indices have been developed through the integration of the indicators based on the LiSeRA framework specified dimensions and sub-dimensions.The LiSeRA framework consists of two major segments, livelihood dimension and resilience dimension, which are integrated within the governance parameters, well defined by the various legislations, guidelines, laws etc. Livelihood dimensions include five capitals derived from the theoretical principles of sustainable livelihood capitals; Human, Physical, Natural, Financial and Social . These cOn the other hand, community-based vulnerability principles provided the foundations for resilience dimensions, further categorized into three sub-dimensions; Absorb, Response, and Recovery. The LMB communities’ capacity to absorb the impacts and stressors primarily relies on their planning and risk reduction strategies, such as flood, and water management infrastructures, advisories and early warning systems, and innovative practices, tools, and technologies in agriculture . SimilarThe LiSeRA toolkit library has been developed with 58 indicators for resilience and 59 indicators for livelihood security. The resilience indicators are categorized into three dimensions; Absorb, Manage/Respond and Recover, each with four sub-dimensions. Similarly, livelihood security indicators are categorized into five dimensions; human, physical, natural, social, and financial.The flowchart in In the next stage, several local workshops were conducted with stakeholders including community people, government officials and researchers in the LMB region to discuss the assessment framework and the identified indicators. These discussions were used to validate the indicators and parameters. Additionally, the stakeholders also conducted pair-wise comparison among the indicators, which was later used to generate their comparative weightages through the Analytical Hierarchical Process (AHP). After the computation of indicator weightage, the algorithm for calculation of livelihood security and resilience indices using the indicators was developed. A six point scale  was developed to normalize the values of quantitative (objective) and qualitative (subjective) data pertinent to the indicators. This algorithm was then used to develop the LiSeRA toolkit, in MS Excel and ‘R’ programming package that provides the computed assessment indices in tabular and graphical format.The LiSeRA Microsoft Excel based toolkit has a dashboard that shows the real-time update of the calculations for livelihood and resilience dimensions indices for the study area based on the inputs given in the toolkit. Two separate dashboards have been prepared.Dashboard Livelihood  shows thDashboard Resilience  shows th•Dimension/sub dimension weightage (D Wt./SD Wt.): The weightage for the dimension and/or sub-dimension within the livelihood or resilience index.•Code: The unique code representation for the indicator.•Indicator: The indicators within each dimension and sub-dimension•Indicator description (measurement): A detailed description of the indicator including the most suitable index of measurement .•Indicator Wt.: The weightage assigned to the indicators.•: The adjusted value of indicator weightage is computed automatically by multiplying the dimension, sub-dimension weightages and the indicator weightages.Adjusted Indicator Wt•References: Sources of journal articles, publications and documents for the respective indicators.The indicator library provides a brief overview of the dimensions, sub-dimensions, and indicators in the livelihood and resilience indices. Along with this, it also displays the weightages assigned to each of the dimensions, sub-dimensions and indicators and allows for modification (if required) during the assessment process.•Type of indicator: Displays the type of indicator and measurement index (subjective or objective)•Effect on livelihood/resilience: The effect of the indicator on the livelihood or resilience indices •Input value: The input value for the particular indicator computed based on the subjective or objective assessment of the study area by the researcher. The input value ranges from 0 (Absent/Very Low) to 5 (Very High).•Indicator Wts: The adjusted weightages for each indicator (refered to from the indicator library sheet).•Value: The total value of the indicator in the livelihood or resilience index is computed by multiplying the input value with the indicator weightage.This sheet will be used to input the values for the individual indicators based on the subjective or objective assessment of the study area by the user. Separate sheets have been designed for livelihood and resilience indices. The instructions for placing the input values are shown in the top row of the sheet and described in the following sections. In addition to the fields already described earlier in the indicator library, the input values have the following fields,Step 1: Select and input the dimension, sub-dimension, and indicator weightage for the assessment.•The weightages for dimensions, sub-dimensions and indicators must be input in the Indicator Library sheets  & 4Table•The general instructions for inserting the values in the sheet are placed in the first row.•The current weightages of the indicators in the LiSeRA toolkit have been generated from pairwise comparison and AHP based on the opinions of experts and stakeholders in the LMB communities.•User may choose to continue your assessment with the same weightages, or generate and enter new weightages based on your own indicator weightage assessment process.•The weightages of the respective dimensions and indicators must be placed in the ‘Indicator Library_Livelihood’ and ‘Indicator Library_Resilience’ sheets.•In the ‘Indicator Library Livelihood’ sheet, the global weightage for five Livelihood dimensions  is entered in the column marked ‘Dim Wt.’. Similarly, indicator weightages is entered in the column marked ‘Ind. Wt.’. It must be ensured that the sum of weightages for five dimensions and twelve indicators in each dimension equals to 1 (One).•The similar process must be done to enter the weightages of the dimension and indicators in the resilience dimensions, in the “Indicator Library_Resilience” sheet.Step 2: Input values for livelihood and resilience dimension indicators•The values for indicators within the livelihood and resilience dimension must be placed in the ‘Input Values_Livelihood’ and ‘Input Values_Resilience’ sheets respectively  & 6Table•The general instructions for inserting the values in the sheet are placed in the first row.•Before inserting the values for the indicators, measurement index (description of indicator including the metric of measurement), the type of indicator (subjective or objective), and the effect on livelihood or resilience (positive or negative) must be checked carefully.•○For objective indicators, a normalization scale must be developed to categorize data obtained for the study area into six levels: 0 – lowest, 5 – highest.○For subjective indicators, subjective assessment must be conducted in the study area. The information collected must be categorized into six categories and respective input values as shown in the Input values must be accurately chosen based on the type of indicator and the effect of the indicator on the livelihood and resilience dimensions as follows,•In the case of both positive and negative indicators, the input data will follow the same scaling. For both indicators, only whole numbers should be entered, without any signs (-/+). The toolkit has been calibrated to automatically assign negative values to the negative indicators.•After determining the values for the indicators, the input values must be placed in the respective columns; Column G in ‘Input Values_Livelihood’ sheet  and Colu•Once the values for the indicators are placed in the respective fields, the adjusted values are automatically calculated by multiplying the input value with the indicator weightage.Step 3: Check tabular and graphical outputs•The outputs of the livelihood security and resilience will be generated in the LiSeRA dashboard.•The outputs will be generated in tabular (matrix) and graphical form through radar plots see , 3Fig. 2•Dimension and sub-dimension values: The matrix displays the values of each indicator computed through the calculation of indicator weightage and input value.•Sum: The total sum for dimension (or sub dimension) for livelihood and resilience is shown.•% of ideal value: The percentage of sum of livelihood or resilience dimensions and sub-dimensions with respect to the ideal value The LiSeRA toolkit has been developed through a comprehensive review of literature, and inputs from stakeholders including experts, government officials, and local community members who are directly involved in planning and implementing risk reduction strategies and actions. The toolkit is intended for researchers, development planners, and policymakers to understand the linkages between livelihood and resilience and conduct quantitative assessments to generate livelihood and resilience indices for different levels . Additionally, the toolkit also serves as a reference for researchers and practitioners in identifying critical indicators that can be used to plan and evaluate risk assessment and management actions within the LMB communities. Livelihood security encompasses the people's ability to cope with natural and anthropogenic hazards and threats such as irregular weather patterns, resource constraints, epidemics and diseases, and market fluctuations that contribute to the sustainability of their livelihoods. Future research should focus on developing well-informed resilience status maps, which include the interdependency parameters of various infrastructures, such as hydrological infrastructures that support livelihood , electricity, transit as well as interactions between other systems. Finally, the LiSeRA framework focuses on assessing livelihood security in the river basin system; however, its application can be extended to a wide range of livelihoods and other geophysical settings.Indrajit Pal: Conceptualization, Methodology, Data curation, Formal analysis, Writing – original draft, Writing – review & editing. Ayush Baskota: Methodology, Formal analysis, Writing – review & editing. Ganesh Dhungana: Conceptualization, Methodology, Data curation, Formal analysis, Writing – original draft, Writing – review & editing. Parmeshwar Udmale: Conceptualization, Methodology, Data curation, Formal analysis, Writing – original draft, Writing – review & editing. Mayuri Ashokrao Gadhawe: Methodology, Data curation, Formal analysis, Software. Puvadol Doydee: Methodology, Data curation, Writing – review & editing. Tanh T.N. Nguyen: Methodology, Data curation, Writing – review & editing. Seak Sophat: Methodology, Data curation, Writing – review & editing. Sreejita Banerjee: Methodology, Writing – review & editing.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Supported accommodation intends to address challenges arising following release from prison; however, impact of services, and of specific service components, is unclear. We describe key characteristics of supported accommodation, including program components and outcomes/impact; and distil best-evidence components.We conducted a systematic review, searching relevant databases in November 2022. Data were synthesised via effect direction plots according to the Synthesis Without Meta-analysis guidelines. We assessed study quality using the McGill Mixed Methods Appraisal Tool, and certainty in evidence using the GRADE framework.Twenty-eight studies were included; predominantly cross-sectional. Program components which address life skills, vocational training, AOD use, and mental health appear to positively impact criminal justice outcomes. Criminal justice outcomes were the most commonly reported, and while we identified a reduction in parole revocations and reincarceration, outcomes were otherwise mixed. Variable design, often lacking rigour, and inconsistent outcome reporting limited assessment of these outcomes, and subsequently certainty in findings was low.Post-release supported accommodation may reduce parole revocations and reincarceration. Despite limitations in the literature, the findings presented herein represent current best evidence. Future studies should clearly define program components and measure their impact; use analyses which reflect the high risk of adverse outcomes, such as time-to-event analyses; and consider outcomes which reflect the range of challenges faced by people leaving prison.Registration: PROSPERO registration CRD42020189821.The online version contains supplementary material available at 10.1186/s12954-023-00832-8. The global prison population exceeds 11 million, with the rate of growth exceeding that of the general population , or are The challenges for people after release from prison have been well documented –8, incluEvidence from cohort studies suggests interventions targeting post-release challenges can have a positive impact on social, health, and criminal justice trajectories –20. AssiPost-release housing instability is particularly challenging because it increases the difficulty of meeting community corrections requirements and, therefore, the likelihood of parole breaches and revocations , 22. ComA 2018 scoping review sought to identify the effectiveness of post-release supported accommodation in improving criminal justice and health outcomes, including physical health, mental health, and substance use issues, and sought to identify the program components associated with positive outcomes for people released from prison . The revThe risk-needs-responsivity model for assessment and treatment for people who experience incarceration, includes three core principles: to match the level of service to a person’s risk of reoffending (risk), assess criminogenic needs and target them in treatment (needs), and tailoring interventions to the learning style, motivations, abilities, and strengths of clients  on 5th May 2020, with updated searches completed on 22nd September 2021 and 9th November 2022. We used a comprehensive set of search terms pertaining to people in or leaving custody; release from custody; and supported housing, developed in consultation with a research librarian , and reporting is in line with the PRISMA guidelines .We created a Zotero (version 6) library to catalogue studies and remove duplicates, and uploaded the remaining references to the Covidence platform  to complInitial title and abstract screening was conducted by one reviewer (DG) due to resource constraints. Subsequently, full texts were independently screened for eligibility by two reviewers . Discrepancies were resolved through discussion and referral to a third reviewer as needed.For the purpose of this review, “prison” refers to all types of adult correctional institutions . Supported accommodation refers to a temporary, transitional residence for adults recently released from prison, coupled with a therapeutic component . Studies were included if they were conducted among adults aged 18 years or older who had been released from prison (no specific time frame since release was applied) and who received any form of supported accommodation. Included studies had to provide a sufficiently detailed description of the supported accommodation program components, such as details of the accommodation type, as well as the type and extent of support provided, factors targeted by services, and structure or restrictions of the program as assessed by the reviewers. We included any study design, including but not limited to evaluations of supported accommodation services and/or their program components, as well as protocols where supported accommodation and therapy was described but no outcome data were reported.Studies were excluded if they were conducted in child and youth services or where the mean client age was < 18 years at intake, or if the service’s primary focus was on an area other than supported accommodation . Services that did not exclusively focus on these areas, but offered counselling or other support for substance use disorders or mental health problems as part of their program, were included.Given the substantial variation in study and service type and outcomes measured, a meta-analysis was deemed a priori to not be appropriate, and a narrative synthesis was planned. We used the Synthesis Without Meta-analysis (SwiM) guidelines  to synthData for each study were extracted and summarised into spreadsheets developed specifically for this review. All studies were extracted by the lead author, with 25% of studies extracted by a second person to ensure accuracy. Any discrepancies were resolved through discussion.The characteristics of supported accommodation services are presented in Additional file Data were extracted regarding nine pre-determined characteristics relating to supported accommodation: (1) year of publication; (2) country of study; (3) study type; (4) gender of clients; (5) supported accommodation type; (6) supported accommodation description ; (7) program components; (8) outcomes/impact of program (including outcome measures used); and (9) summary of the outcomes/impact of the clients.The methodological quality of studies was appraised using the McGill Mixed Methods Appraisal Tool (MMAT); , 31, whiTo assess our certainty of the synthesis findings, relevant components of the GRADE Framework incarcerated, including sociodemographic and health factors such as housing , substanIn the context of such a broad range of known challenges experienced by people released from prison, which contribute to the risk of reoffending, and the wide range of factors targeted by supported accommodation services, detailed risk assessment which incorporates identification of client needs is important to ensure appropriate service delivery. While some of the included studies described program eligibility criteria which included risk assessments , 59, 61,Further to the already described challenges related to scalability and replicability, the lack of clear program component definitions or evidence of standardisation in the academic literature creates challenges in understanding how program components can be delivered in a responsive manner. This includes targeting and dosing appropriate program components according to client risk and needs, as well as their strengths and motivations. Embedding data collection processes in service delivery may increase the opportunity to identify client risk level and needs, as well as identifying dose information. This could also contribute to measurements of the impact of certain program component on specific outcomes.Only 12 of the 28 included studies met all methodological quality criteria  resulting in mixed effect directions. Program evaluations need to be undertaken to a higher standard to allow for better understanding of effectiveness. As a result, we are limited to the information that was reported by the authors in the included literature regarding program components of these services, and work remains to identify the impact of specific components on specific outcomes. While randomized control trials of supported accommodation for people released from prison may not be feasible due to ethical considerations regarding assigning individuals to substandard housing conditions when at risk of homelessness, novel approaches to evaluation design may be employed to improve the quality of this evidence. Future research could usefully integrate multiple data sources including linked administrative data with expertise of service providers and clients to identify program components and their impact on client outcomes.Many studies evaluated outcomes across multiple facilities, without clarification around the consistency of intervention delivery. This, coupled with varied detail provided describing supported accommodation services and their program components, and varied study types created challenges when analysing data in this review. Further, we were limited in our scope to compare the effectiveness of interventions because of the above-mentioned inconsistent definitions as well as the variation in how these program components were combined in service delivery.Finally, most studies identified in our review were drawn from the United States (Additional file Given the fragmented nature of the literature, we were unable to draw unambiguous conclusions regarding the effectiveness of supported accommodation services following release from prison on either legal or health outcomes. Relatedly, we were unable to identify specific program components consistently linked with better client outcomes. Both these limitations could be addressed through primary research studies that adopt rigorous methods, clearly document program components, and explore important health as well as legal outcomes. Finally, having only one reviewer screening articles at the title and abstract stage may have had consequences for screening consistency and increasing possible selection bias.People who are released from prison experience social, financial, and health challenges; supported accommodation aims to help improve outcomes during the post-release period. This review represents the current best available evidence regarding the key characteristics of these services, however we identified considerable variability in how supported accommodation services operate and are evaluated. We found a positive effect of supported accommodation on reincarceration and parole revocation outcomes, although other outcomes had mixed direction of effect. Vocational training and employment skills and life skills program components may have a positive effect on parole revocations and reincarceration outcomes, however these findings should be interpreted with caution. We recommend that future research evaluates the impact of specific program components on client outcomes, and that studies consider outcomes which reflect to the range of challenges experienced following release from prison, including housing, mental and physical health.Additional file 1. Table 1: Key characteristics of identified services, and their effectiveness.Additional file 2. Supported accommodation: A systematic review: Appendices.