Health literacy has been recognized as a significant social determinant of health, defined as the ability to access, understand, appraise, and apply health-related information across healthcare, disease prevention, and health promotion. This systematic review aims to understand the relationship between health literacy, blood pressure, and dietary salt intake. A web-based search of PubMed, Web of Science, CINAHL, ProQuest, Scopus, Cochrane Library, and Prospero was performed using specified search/MESH terms and keywords. Two reviewers independently performed the data extraction and analysis, cross-checked, reviewed, and resolved any discrepancies by the third reviewer. Twenty out of twenty-two studies met the inclusion criteria and were rated as good quality papers and used in the final analysis. Higher health literacy had shown to have better blood pressure or hypertension knowledge. However, the relationship between health literacy with dietary salt intake has shown mixed and inconsistent findings. Studies looking into the main four domains of health literacy are still limited. More research exploring the links between health literacy, blood pressure, and dietary salt intake in the community is warranted. Using appropriate and consistent health literacy tools to evaluate the effectiveness of salt reduction as health promotion programs is required. Cardiovascular diseases (CVDs) remain one of the worldwide leading causes of death, leading to the deaths of 17.9 million people annually . HoweverExcessive salt intake is the main contributing factor towards hypertension, with strokes accounting for 62% and coronary heart disease for 49% . AccordiBetween 2003 and 2011, population salt intake had reduced by 15% with the implementation of the United Kingdom’s salt reduction policy, where 85 product categories were set to lower salt content via independent monitoring. It appeared that there was a decrease in CVD mortality . FollowiLooking at the current trends, health literacy research is scarce. Health literacy is defined as the ability to access, understand, appraise, and apply health information in everyday life to make judgments and decisions about healthcare, disease prevention, and health promotion to maintain or improve one’s quality of life over time . The conOne of the most cost-effective strategies to fight NCD is to improve health literacy ,21. HoweA systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting criteria (PRISMA 2020) and was designed according to PICOS  criteria . The revA systematic literature search was conducted to identify studies that reported on the relationships between health literacy and blood pressure and dietary salt intake in people over the age of 18 years. It focused on the association between health literacy with dietary salt and blood pressure, using quantitatively validated instruments for health literacy and dietary salt and blood pressure. For intervention studies, only explicit interventions aiming at lowering blood pressure and dietary salt were considered. Studies that did not use any health literacy tools did not report any outcome of interest, were not published in English or Mandarin, were rated as poor or fair quality, or involved patients with specific conditions were all excluded.A web-based search of PubMed, Web of Science, CINAHL, ProQuest, Scopus, Cochrane Library, and Prospero was performed. Databases search was supplemented with grey literature, internet searches , reference lists of studies included in the systematic review, and manual search. The last search was run on 1 March 2021.The search was limited to English and Mandarin literature, published from January 2010 to March 2021, and will be re-run prior to the final analysis. Keywords and MESH terms, “health literacy” or “literacy” OR “numeracy” with “salt” or “salty” or “sodium” or “hypertension” or “blood pressure” were utilized and combined with the search using Boolean terms such as “AND” and “OR” .Articles were chosen in three stages: selection based on titles, followed by abstract consideration, and assessing the full text. Bibliographic information such as author, publication year, title, and journal, study design, setting, country, inclusion and exclusion criteria, subject recruitment, age, gender, and the study’s duration and dates were all acquired. Any mandarin language papers were translated by one of the reviewers.The data gathered were then exported to Microsoft Excel from Mendeley, a reference manager software, and full texts. Two reviewers independently performed the data extraction and analysis, cross-checked, and reviewed and resolved any discrepancies by the third reviewer.To meet the objective of the review , tools utilized for assessing subjects’ health literacy, the appropriateness of blood pressure and salt intake measurement, and the outcomes of the associations were included. Other variables such as sociodemographic characteristics, knowledge, attitude, practice (KAP), and nutritional status were also extracted. The results of the measurements and the statistical methods used to assess the associations between them were then recorded along with the related conclusion and recommendations. All outcomes compatible with the outcome domain were sought in each study. The original authors of the studies were contacted when more information about the study outcomes or other details were needed.Observational studies were assessed using the Newcastle–Ottawa quality assessment scale adapted for cross-sectional and cohort studies, measuring the selection, comparability, and outcomes. For interventions studies, random sequence generation, allocation concealment, selective reporting, other bias, blinding of participants and personnel, blinding of outcome assessment, and missing outcome data were all assessed using Cochrane’s collaboration tool. Quality scores were rated as “Good”, “Fair” or “Poor” quality. Each study’s risk of bias was independently assessed by two reviewers, and any disagreements were discussed with the third author. The bias assessment was reported in the tabulation.Binary and continuous outcomes were gathered, and effective measures such as mean, mean difference, and odds ratios of the outcomes were used to synthesize and present results. The review also included other calculations/statistics, such as quartiles.The results were performed in tabulation and visual display of methods. A narrative synthesis of findings detailing the association between health literacy with blood pressure and dietary salt intake was performed.After eliminating duplicates from the databases, 1960 articles were identified. A total of 39 full texts were analyzed after the title and abstract screening. Twenty-two studies out of 39 met the requirements for inclusion, while 17 were excluded as they did not fit the criteria, did not report any outcome of interest, did not use any health literacy instrument, and involved patients with specific diseases other than hypertension. After quality assessment, two were removed as they were poor or fair quality papers ,23, and N = 7), Brazil (N = 2), Turkey (N = 2), Switzerland (N = 1), China (N = 1), Japan (N = 2), Iran (N = 2), Singapore (N = 1), Thailand (N = 1), and Cambodia (N = 1). All of the studies illustrate the relationship between health literacy with either blood pressure control or salt intake. Seventeen papers measured the associations between health literacy and blood pressure control, while three papers measured salt intake. Participants in studies include adults aged 18 years and above and the elderly, mostly with hypertensive conditions (N = 17). All studies used validated health literacy instruments though they varied considerably. Health literacy was most commonly measured by using Rapid Estimate of Adult Literacy in Medicine (REALM), a short version of the Test of Functional Health Literacy in Adults (STOFHLA), Newest Vital Sign (NVS), and Brief Health Literacy Screening (BHLS). The majority of studies or tools used to assess health literacy did not include all four main domains of health literacy; the ability to access, understand, appraise and apply health information. Out of 20 studies included, most studies assessed one’s ability to understand (n = 15), followed by appraise (N = 9), and apply (N = 9) health information, however very limited is known about the ability to access (N = 6) and the overall four domains of health literacy (N = 5). Most studies only assessed three health literacy domains at most.There were 18 cross-sectional studies, one cohort study, and one RCT among the 20 papers included. The studies were conducted in United States  and a twelve-item scale that assessed nutrition practices based on a low salt, DASH diet, and HL-SR . Of the 22 papers included initially, 20 are graded as good, the other two as fair and poor quality, hence were excluded from synthesis . DetailsHealth literacy status varied. This could be due to the participants’ diverse backgrounds, as well as differences in the types of tools and reporting methods used. Most studies categorized health literacy into two or more groups; limited and adequate; limited, marginal, adequate; problematic, inadequate, sufficient, excellent. Four studies presented health literacy status as mean and standard deviation ,30,31,41N = 17) was the most commonly done, followed by salt (N = 3). One study [salt N = . One stune study ,36 out op < 0.05; N = 12), while four studies reported non-significant associations [There are two outcomes in the blood pressure category; blood pressure control and blood pressure/hypertension knowledge. The majority of studies looking at health literacy and blood pressure control found a significant positive association . These include a study using gold standard salt intake measurement, 24 h urine collection [Three studies explored the association between health literacy and dietary salt intake. The majority of studies found non-significant associations , appraise (N = 9), apply (N = 9), and followed by understand (N = 15). A few tools assessed all four domains of health literacy, namely European Health Literacy Survey Questionnaire (HLS-EU-Q), European Health Literacy Survey Questionnaire 47-item (HLS-EU-Q47), Health Literacy for Iranian Adults (HELIA), and a tool adopted from Ishikawa et al. (2008) [Out of 20 studies, only five measured all four domains of health literacy according to Sørensen et al. (2012); one’s ability to access, understand, appraise and apply health information ,25,28,32. (2008)  assessinThe causes of poor hypertension management are multifaceted, which include obesity , medicatAlthough health literacy research has improved over the last decade, before 2012, there was no consensus on the definition or its conceptual dimensions, restricting measurement and comparison possibilities. In addition, there were 16 types of health literacy tools used in the included studies, with only five studies assessing the main four domains of health literacy ,25,28,32People may now access a wide range of medical information through smartphones. More significantly, regardless of the skills, anyone may now develop health information and make it available to others  which maThese domains highlight the differences between health literacy and the well-known KAP studies that assessed the respondents’ knowledge, attitude, and practice. In comparison with health literacy, KAP does not assess the extent of health literacy which dives into the aspect of one’s ability to access, understand, appraise and apply health-related information in healthcare, disease prevention, and health promotion, which has been proven to be a critical health determinant and may have been overlooked until recent years. Therefore, limited studies using appropriate health literacy tools that include the leading four domains highlight the need for more research utilizing the domains in the future.In terms of blood pressure control outcomes, higher health literacy patients have better control of hypertension, according to most research, and vice versa. However, these findings were inconsistent with a study done in three primary clinics in Nashville with approximately 23,483 hypertensive patients, where it appeared that patients with higher literacy tend to have higher systolic and diastolic blood pressure. Patients with lower health literacy, they claimed, were at least are more inclined to seek regular treatment than those with adequate health literacy, as seen by the higher frequency of clinic visits. However, because these factors may reduce the impact of health literacy, a sensitivity analysis was carried out to adjust the number of clinic visits, and the outcome was unaffected . SurprisThere appears to be a lack of studies exploring the link between health literacy and salt intake currently. Therefore, more investigation is required to justify the associations. The current findings on the association are inconsistent ,41,42. OInterestingly, individuals with adequate health literacy had a 6% higher chance of adhering to the low salt diet  than those with limited health literacy, but the results remained non-significant. Otherwise, literacy skills were found significantly associated with health literacy sodium restriction. However, because the survey was more health literacy oriented, the tool utilized may not be powerful enough to reflect one’s salt intake. Based on current evidence, it has shown promising findings that health literacy could potentially be associated with understanding salt intake but not actual sodium intake that requires a robust tool to evaluate it appropriately, such as from urinary excretion or habitual dietary intake. It is important to highlight that the significant factor in the raised blood pressure is a high salt intake, which is accountable for CVD such as strokes and heart attacks . The strThis systematic review also discussed the relationship between health literacy and hypertension or hypertension knowledge. Health illiterate individuals are likely to have poor hypertension knowledge. Hypertension knowledge and health literacy were found to be significantly linked according to two studies in the review ,41. Ko eThe collective evaluation revealed some noteworthy gaps in this area of research, including more research, which is needed to better understand the relationship between health literacy and salt intake, scarcity of evidence among the general population, and appropriate health literacy tools that assess all the crucial domains of health literacy.To the best of our knowledge, our study is the first of its kind to have systematically reviewed and discussed the lack of utilization towards the main domains of health literacy. Furthermore, existing evidence and gaps were identified, and aside from quality assessment, to reduce the risk of bias, the review included grey literature.Our review also has some limitations. The scope is limited by the available evidence in the literature. Most studies included were cross-sectional, which limits the ability to identify the causal relationship. Cohort or intervention studies should be taken into consideration in the future to produce more valuable findings. In addition, the majority of studies were done among hypertensive individuals. Studies on the general population’s health literacy are still limited. There were only a few studies conducted investigating the associations between health literacy and salt intake. The variation of tools and methods used to interpret the results and outcomes were some of the limitations during the review process. These variations rendered comparison across studies difficult.It appears that the majority of hypertensive individuals with higher health literacy tend to have better blood pressure control. However, the evidence of health literacy on salt intake itself is still scarce. Future research is needed to assess the applicability of health literacy with salt intake and blood pressure in other resource-limited settings.


This is the protocol for the development of a Campbell Collaboration evidence and gaps map (EGM). The primary objective of this evidence and gap map (EGM) is to answer the following question: (1) What is the evidence connected with the use of information and communications technologies (ICT) for preventing and responding to sexual and gender‐based violence (SGBV) against women and children in lower‐ and middle‐income countries (LMIC)?(a) the EGM will provide a structured and accessible contextual framework for research to stakeholders and policymakers in SGBV and ICT; (b) the EGM will identify gaps in the available ICT and SGBV evidence; (c) the EGM will identify clusters of evidence suitable for systematic review; and (d) the EGM will look for and build connections between related areas of research in ICT and SGBV.(a)Does the use of ICT prevent SGBV against women and children in LMIC?(b)How effective is ICT at improving access to quality services for SGBV survivors in LMIC?(c)Does the use of ICT contribute to effectively achieving intermediate outcomes that lead to the prevention of SGBV against women and children, and/or improving access for SGBV survivors to response services in LMIC?(d)What are the enabling factors associated with the implementation of ICT and SGBV interventions?As part of identifying the evidence connected with the use of ICT for preventing and responding to SGBV we seek to answer the following questions based upon the available evidence: It occurs in many forms and contexts including IPV ; sexual violence; conflict‐related sexual violence; forced and early marriage; trafficking; female genital mutilation; femicide; homophobia and transphobia; and sexual harassment and abuse. What unites these diverse manifestations of violence is that, at their core, they are violent acts associated with the socially assigned gender differences between males and females, often exploiting individual and social power imbalances. SGBV is also often a reaction to perceived threats to the same socially constructed gender roles or norms.MEASURE Evaluation,Few experts challenge the assessments identifying the consequences of SGBV. Some studies and a systematic review outlining effective interventions and approaches to reducing IPV, for example, have added to the SGBV evidence base.  who have experienced conflict‐related sexual violence ranges from 4% to 24% (depending upon the methodology used)  to address multiple issues in LMIC, has increased exponentially in the past decade UNESCO, . This trICT interventions can facilitate strategies that are known to be effective for achieving certain outcomes, but face implementation challenges. For example, in the field of HIV, adherence to antiretroviral treatment is known as effective for treating HIV by reducing viral load, but lack of oversight in ensuring patients regularly adhere to their prescribed regimens is a common obstacle. The use of ICT (mobile phone reminders) has been proven as an effective strategy to ensure that patients adhere to their appointed regimens  and the World Bank, have recognised and acknowledged the increased use of ICT to both prevent and respond to SGBV globally  provide an initial analysis and functional categorisation of mobile phone applications addressing violence against women , increasing evidence has also raised concerns about the role of ICT in exacerbating SGBV . Modes of ICT include mobile phones, tablets and web‐based applications using laptop computers. We will include ICT interventions for the prevention of SGBV against women and children, as well as for responding to SGBV by improving survivors’ access to services, and preventing the re‐occurrence of SGBV. We will achieve intermediate outcomes that are part of causal pathways for (1) preventing SGBV against women and children in LMIC; and (2) responding to SGBV by improving survivors’ access to services. These intermediate outcomes will include those connected with evidence‐based interventions contributing to the prevention of SGBV under the RESPECT and INSPIRE frameworks.The scope will also include using ICT to exclude the uses of ICT if they are not specifically and purposefully used to deliver or fill gaps in prevention and response interventions for SGBV. We will exclude uses of ICT if they are not linked specifically to some aspect of gender. We will include literature that studies the unintended consequences of ICT interventions.We will We will identify ICT supported interventions that have as an objective either (1) SGBV prevention; and/or SGBV response (improved access for SGBV survivors to services); or (2) an intermediate outcome that is part of the evidence‐based causal pathway to either SGBV prevention, or improved access for SGBV survivors to services (with reference to the RESPECT and INSPIRE frameworks). These intermediate outcome areas are connected with root causes of SGBV based established by global evidence. We will attempt to identify only studies related to interventions if they are delivered using ICT, and describe the role of ICT in facilitating the delivery of the intervention. These studies may compare cohorts using ICT interventions with non‐technology interventions, or with no‐intervention at all.Illustrative examples of prevention interventions using ICT include: gaming applicationsIllustrative examples of response interventions using ICT include: web‐based applications showing where health and counselling services for SGBV can be accessed; links to online counselling for survivors to prevent the re‐occurrence of SGBV; and WhatsApp support groups for survivors of SGBV , governments, or a collaboration of some or all that may also include universities. A separate technology partner, unless the group, NGO or government has internal technological capacity, provides the technological input, coding the ICT tool whether it is a mobile phone application and/or web‐based laptop computer application, conducting a feasibility assessment , and delivering necessary training to the targeted users of the technology. The technologists work (or are supposed to work) hand‐in‐hand with the programme specialists  to ensure the interventions supported by technology are appropriately designed deployed, and are most importantly, delivered in accordance with the “SGBV interventions may also be delivered in the form of applications that can be downloaded onto phones, tablets and computers , and used without additional involvement of external parties.women and girls in LMIC;boys in LMIC ; andothers who are vulnerable to SGBV, including transgender and gender‐nonconforming persons, whether or not they identify as female.For the purpose of this EGM, the primary targeted groups will be:We define “children” based upon the definition under the Convention on the Rights of the Child, to “include male and females being below the age of eighteen years unless under the law applicable to the child, majority is attained earlier”  in LMIC;intimate partners in LMIC;service workers  in LMIC;organisations working in the area of SGBV or in any of the outcome areas relating to the prevention and response of SGBV identified under the RESPECT and INSPIRE frameworks; andcommunities and community leaders in LMIC.However, we will also include interventions that target intermediary groups who are part of the causal pathway to preventing SGBV against women and children, and increasing access to SGBV services for survivors including preventing the recurrence of SGBV:Primary prevention: Aimed at the whole community or at men and boys specifically to stop SGBV before it occurs. Addresses root causes of violence : Aimed at survivors and perpetrators of SGBV. Implemented after the violence has occurred and focuses on minimising the impact of violence, restoring health and safety, and preventing from occurring again ; focus population; whether it is to prevent or respond to SGBV; and the quality and the diversity of the body of evidence that exists.There are few to no systematic reviews identifying evidence around the use of ICT for outcomes related to SGBV against women and children in LMIC. Those that exist are limited in scope and focus on higher income regions  for preventing and responding to sexual and gender‐based violence (SGBV) against women and children in lower‐ and middle‐income countries (LMIC)?a.The EGM will provide a structured and accessible contextual framework for research to stakeholders and policymakers in SGBV and ICT.b.The EGM will identify gaps in the available ICT and SGBV evidence.c.The EGM will identify clusters of evidence suitable for systematic review.d.The EGM will look for, and build connections between related areas of research in ICT and SGB.In addition to (1), we will also answer the following questions based upon the available evidence we find:2.Does the use of ICT prevent SGBV against women and children in LMIC?3.How effective is ICT at improving access to services for SGBV survivors in LMIC?4.Does the use of ICT contribute to effectively achieving intermediate outcomes that lead to the prevention of SGBV against women and children, and/or improving access for SGBV survivors to response services in LMIC?5.What are the enabling factors associated with the implementation of ICT and SGBV interventions?33.1EGMs represent a relatively new approach to identifying and classifying available research and evidence for a broad scope or topic, such as ICT and SGBV. EGMs offer a rigorous and systematic process to “map” what evidence exists and where also gaps in evidence exist. EGMs are ideal for topics where little understanding of the research landscape exists; or those that incorporate several potential interventions with various outcomes, but may lack widely available studies. EGMs differ from systematic reviews in that they identify clusters of evidence that may be further analysed by meta‐analysis, with each cluster representing a potential systematic review in itself , a global steering committee of SGBV and ICT experts, and through reference to existing SGBV evidence‐based evidence , theories and policies. In addition to the EGM, we are also conducting a landscape review of ICT and SGBV interventions in LMIC that will capture work being done by activists, civil society, NGOs, and other groups that are not represented or published in traditional academic and research settings (and therefore likely to not be identified by the systematic searches of peer‐reviewed literature).3.3We have launched a steering committee of SGBV and ICT experts, including representatives from the global South, who are assisting in the conceptualisation of the framework. The committee includes academics, civil society actors, and activists. The committee has been assisting us to identify key stakeholders for informant interviews to further help guide the EGM. Additionally, we are conducting an in‐depth landscape review to help identify where ICT and SGBV interventions are being implemented on the ground. The landscape review will identify other key stakeholders for interviews and feed into the EGM.3.4intermediate outcome that contributes to the primary outcome (or impact) of either preventing SGBV or responding to SGBV . Often there is more than one intermediate outcome, attributable to multiple interventions, which together form a causal pathway leading to the primary outcome (or impact) such as SGBV prevention   for achieving intermediate outcomes that contribute to, or are inferred, based upon available evidence, to contribute to, SGBV prevention and response primary outcomes. The research team acknowledges that interventions, for the purpose of ultimately preventing and/or responding to violence, may have the objective of achieving an Theories of Change that contribute to or are prerequisites leading to primary outcomes (or impact). Often it is difficult to measure primary prevention outcomes or impact . Established evidence around the prevention of violence supports inferences that achieving one or more intermediate outcomes will necessarily lead to, or contribute to prevention , or effective response interventions (greater access to services). We anticipate that studies may tend to more likely evaluate the effectiveness of an intervention in achieving an intermediate outcome. Based upon evidence, we may be able to infer that the intermediate outcome will either directly lead to, or is a necessary ingredient for achieving the primary outcome/impact .We will include studies that evaluate intermediate results that may be components of We will identify studies that target and measure outcomes on groups other than women and children. These targeted intermediary groups include SGBV service providers , potential and actual SGBV perpetrators (including intimate partners), community members, and organisations.The World Health Organisation's RESPECT Women framework for the prevention of violence against women (including SGBV) is useful to conceptualise intervention SGBV outcomes  and intervention outcome.The conceptual dimensions used for coding the EGM will reflect key elements of ICT and SGBV intervention design, organised by: target users, or those for whom the intervention is intended. Primary targets are those who are vulnerable to SGBV, or survivors. This includes especially women and children. This may also include boys, men, and those who are transgender or gender non‐confirming. Intermediary targets are key actors who fall in the intermediate of SGBV's causal pathway. This includes potential or actual perpetrators of SGBV, first responders, organisations, and all others who may influence intermediate outcomes that contribute, or ultimately lead to SGBV primary prevention and access to services outcomes such as community health workers, or medical and social welfare professionals.First, we will look at intervention and outcome. The EGM will be laid out according to two axes: x and y. One axis will present types of ICT interventions. The other axis will lay out intervention outcomes and impacts. While we anticipate that many outcomes will likely measure individual and interpersonal SGBV‐related attitudes, knowledge and behaviours, following evidence‐based existing frameworks , we will also consider structural outcomes at the community and societal level. We also anticipate that some evidence may relate to ICT intervention evaluation . We anticipate using broader outcome codes with more detailed filtering to capture additional nuance for the final EGM. We acknowledge that some overlap may exist between the dimension codes. Interventions which have more than one objective or outcome will be coded more than once as appropriate. However, we will attempt to avoid the overuse of doubling coding.The EGM data will be organised by targeted user according to two main dimensions of ICT: 3.5.1Systematic reviews of experimental or quasi‐experimental studies.Experimental Quasi‐experimental with well‐defined comparison group: that includes a well‐defined comparison group. non‐randomised controlled trials, cohort studies, case‐control studies, and cross‐sectional analytical studies.Rigorously designed qualitative research: guided by precise and clear research questions (RQ); with adequate data collection to address RQ; interpretation of results substantiated by data, and coherence between qualitative data sources, collection, analysis and interpretation. Descriptive qualitative evidence related to implementation or cost‐effectiveness of ICT and SGBV is particularly of relevance.We will include studies without comparisons of cohorts if they examine elements of ICT implementation useful to SGBV and ICT stakeholders, especially those that examine cost‐effectiveness, feasibility of implementation, or acceptability of a given intervention.3.5.2applications, adapting, in part, frameworks developed in the mHealth field, such as the mHealth and ICT Framework for Reproductive, Maternal Newborn and Child Health (RMNCH) , or to address obstacles and challenges in the delivery of an intervention . Accordingly, we will categorise interventions by type of ICT application. We will identify ICT interventions according to common types of ICT Ideally, an ICT intervention will be compared to an existing non‐ICT‐based intervention—for example, tablet‐based screening tools compared to the same tool in paper form, or web‐based workshops on gender attitudes compared to in‐person workshops.1.Education and behaviour change communication2.Data collection and reporting3.Electronic decision support 8.Gaming9.Hotlines10.ReferralsExamples of types of ICT applications (some of which may overlap) may include:For inclusion in our search, all interventions must have gender‐related outcomes see Appendix ppendix A3.5.3Primary, or those vulnerable or survivors of SGBV: women and children, especially girls, those vulnerable to other forms of SGBV (ex. transphobic violence).Intermediaries or those intermediate in the SGBV causal pathway: potential perpetrators, perpetrators, first responders, and any others intermediary agents .We will include studies that focus on two types of populations living in LMIC:We envision two maps within the EGM—one for interventions designed for primary targets and one for intermediaries. Additional tabulation of population type within the two maps will also be included.3.5.4We will identify ICT supported interventions that have as outcome either (1) the primary outcome/impact of SGBV prevention; and/or SGBV response (improved access for SGBV survivors to services); or (2) an intermediate outcome that is part of the causal pathway to either SGBV prevention, or improved access for SGBV survivors to services.With regard to studies with primary outcomes/impact, we do not anticipate identifying many studies that measure changes in SGBV prevalence. We are more likely to identify studies that measure changes in the uptake of SGBV‐related response services.The intermediate outcomes may reflect any of the evidence‐based strategies for preventing SGBV reflected in the RESPECT and INSPIRE frameworks such as transformed knowledge, behaviours, beliefs and norms, environments made safe, social or economic empowerment of women, reductions in poverty, relationship skills strengthened  that do not have an explicit SGBV intent connection. We will exclude interventions that create safe environments (another RESPECT strategy) without a specific intent connection to SGBV prevention.a mobile phone app that helps women recognise risk factors for IPV.Changes in knowledge and awareness by those vulnerable to SGBV about means for avoiding and preventing SGBV. Example: a web‐based format that allows SGBV survivors to report SGBV incidents to police from their mobile phones and directs to local medical services for first‐response.Changes in knowledge and awareness by SGBV survivors about where and how to access SGBV services. Example: a gaming app that helps adolescent boys develop more gender‐equitable attitudes and behaviours.Changes in social norms, attitudes and behaviours amongst men and boys, and intimate partners regarding SGBV which ultimately should lead to reducing incidents of IPV. Example: a social media campaign targeting community attitudes or beliefs regarding common SGBV myths, which ultimately should lead to a reduction of SGBV in the community.Changes in community social norms, attitudes and behaviours towards SGBV. Example: phone‐based tools to assist social workers in better identifying SGBV risk factors or signs of SGBV when making home visits, which ultimately should lead to a reduction of SGBV, increased access to services and/or the re‐occurrence of SGBV.Service providers building improved capacity and capabilities (knowledge) in providing SGBV services to SGBV survivors. Example: a mobile phone application that guides women in women‐led village savings and loan associations, and provides relationship building curriculum for discussion which should contribute to the reduction of IPV.Changes in the economic empowerment of women and family household incomes and improved relationship skills between intimate partners. Example: These intermediate outcomes may be related to SGBV prevention or response. Examples include:3.5.5We are focusing on interventions implemented in LMIC, but may refer to interventions implemented in higher income nations to provide context and for comparison in the descriptive narrative and analysis.We will include ICT interventions that have home‐based individual end‐user settings ; as well as those that may encompass clinical settings (ex. ICT‐based SGBV screening tools). We will include interventions in LMIC. Interventions in higher‐income settings will be excluded from the EGM, but we may refer to interventions in higher‐income settings to provide context in the descriptive narrative and analysis.1.Humanitarian and emergency settings 2.IPV3.Children in the armed forces4.Trafficking5.Schools6.Conflicts, war, fragile states7.Mobile children and women (including migrants)The following settings and contexts will be included, but not necessarily limited to:3.63.6.1Relevant studies will be identified through electronic searches of bibliographic databases, research networks, government policy databanks and internet search engines. The searches will include studies published from 2005 and forward . Results in English, Portuguese and Spanish (languages spoken by the reviewers) will be reviewed. The bibliographies of relevant reviews and included studies will be used to identify additional references for review. We will conduct forward citation searching using the website Google Scholar as this database produces similar results to other search engines.Any changes in eligibility criteria will be agreed prospectively between the members of the review team. These will be documented and reported as a discrepancy from protocol in the manuscript. In the advent of a change in eligibility, we will re‐screen citations.Search terms will be developed based on terminology representative of implementation and dissemination research and include search filters used in previous reviews. We will particularly leverage globally accepted terminology around SGBV in globally accepted frameworks and guidance including INSPIRE: Seven Strategies for Ending Violence Against Children , including content from civil society, feminist groups NGOs and other activist web‐based content relevant to the prevention and response of SGBV in LMIC.The We will review relevant grey literature, developing a separate search strategy including all of the following elements:As SGBV and ICT span multiple disciplines and contexts, social science, public health, education, humanitarian, and ICT related electronic databases will be searched. Search terms will vary by database but will generally include three blocks of terms and appropriate Boolean or proximity operators, if allowed: blocks will include terms that address (1) intervention; (2) population; (3) outcomes.Bibliographic databases to be searched:Association for Computing Machinery (ACM) Digital LibraryAfrican Journals Online (AJOL)Business Source CompleteCampbell Collaboration Library searched through July 2019Centre for Reviews and Dissemination DatabasesCiteSeerXClinicalTrial.govCochrane LibraryEBSCOEducation Resources Information Center EPPI‐Centre Systematic ReviewsGoogle ScholarIdeas/Economist onlineIMISCOEInternational Bibliography of the Social SciencesJournal of Social Work PracticeLILACS MEDLINEMendeleyPILOTS ProQuest dissertations & theses A&IPsychARTICLESPsycINFOPubMedScienceOpenSexual Violence Research Initiative (SVRI)Social Care OnlineSocial Science Citation AbstractSocial Science Research Network (SSRN)SocIndexSpringerLink3.6.3Copies of relevant documents from Internet‐based sources will be made. We will record the exact URL and date of access.Reference lists of included studies and relevant reviews will be searched for potential new literature.Personal contacts with national and international researchers will be considered in order to identify unpublished reports and on‐going studies.3.6.4 OR podcast (tiab)) AND  country or region, (2) age group, , (3) delivery channel/place . In the hard copy multiple 2 × 2 representations of the EGM may be reported. In the online interactive map, the additional dimensions can be used as a filter to select studies meeting those criteria. Provide detailed definitions for each additional dimension. Describe how the different dimensions will be captured in the map.Region and countryICT delivery SGBV context Specific target population Vulnerable populationSector(s) implicated: health, justice/legal, social welfare, education, multi‐sector, etc.Type of studySize of cohortGiven the broad scope of ICT and SGBV, it will be useful to include additional filters that highlight studies by the following (in addition to the dimensions described above):3.7.3Define the unit of analysis for primary studies. Define whether each item represents a report or a study, and what will be done when there are multiple reports for a single study, or when a report covered multiple studies.We will include individual studies with multiple reports as a single study. This includes any studies that are included in more than one systematic review.3.83.8.1Two independent reviewers will first independently screen studies’ titles and abstracts. Disagreements between reviewers will be resolved by consensus. Potentially eligible studies will then be retrieved in full text and these full texts will be reviewed for eligibility, again using two independent reviewers. Disagreements between reviewers will again be resolved via discussion and consensus. If we cannot determine eligibility due to missing information in a report, we will contact the study authors for this information. The completed review will include a table of studies excluded at the full text level of screening and provide rationale for each exclusion decision. We will also publish a PRISMA flow chart to report the screening process and results , study method(s), sample sizes outcomes, etc., we will include categories regarding classification of ICT , general characteristics of, including age categories of ICT users, connectivity and other ICT enabling conditions , type of intervention: (1) Prevention: primary, secondary, tertiary) or 2) Response . We will draw from commonly and generally accepted frameworks for analysing SGBV for children (INSPIRE), and for women ; Minimum Standards for Prevention and Response to Gender‐based Violence in Emergencies.See Appendix 3.8.3While we do not anticipate identifying many reviews, we will use the AMSTAR 2 tool (Shea et al., The overall quality of evidence for each study, we will be rated using the GRADE system (Guyatt et al., Cochrane Handbook for Systematic Reviews of Interventions (Higgins et al., Risk of bias will be assessed independently by two reviewers using the risk of bias tool described in the Content: William C. Philbrick, Jacob R. Milnor, Madhu Deshmukh, Patricia N. Mechael.EGM methods: Jacob R. Milnor, William C. Philbrick.Statistical analysis: William C. Philbrick, Jacob R. Milnor.Information retrieval: William C. Philbrick, Jacob R. Milnor.The authors declare that there are no conflict of interests.The project to develop the EGM is funded by a non‐for‐profit organisation with no competing interest. The funder is not involved in editorial decisions or decisions related to publishing, USA.


Calls for evidence-based approaches to COVID-19 have sparked up discussions on the use of evidence for policy. In this note, we expand these discussions: while the debate has mostly focused on the types of evidence to be used for policy, we argue that the assessment of judgments involved in data practices and evidence production should play a central role in evaluating policy. In this note, we analyse the use of data and evidence as a basis of mitigation measures of the COVID-19 pandemic.Throughout the COVID-19 pandemic, governments around the world have relied on teams of scientific experts to guide their policy-making. Many commentators have criticised these efforts by arguing that COVID-19 policies have a significant flaw: they are not truly evidence-based. A prominent representative of these critiques has been epidemiologist and meta-scientist John P.A. Ioannidis, who claimed that the quality and reliability of COVID-19 research are very low. Ioannidis has criticised many interventions, especially lockdown measures, arguing that pandemic policy runs the risk of becoming a “once-in-a-century evidence fiasco”  are placed on the top of the evidence hierarchy because they are taken to have greater internal validity. These studies control various biases using randomisation and blinding (in the case of RCTs) and strict pre-established guidelines for conducting the analysis . Correspondingly, expert opinion and other types of evidence, for instance from observational studies, are considered to be unreliable because they cannot control possible biasing effects of subjective preferences and confounding. These assumptions about evidence types and assessment explain why many COVID-19 mitigation measures have been criticised as lacking in evidence and quality: because they are often grounded on observational studies or expert opinion.However, evaluating COVID-19 measures on the basis of EBM can be criticized for reasons that have been raised in previous literature critical of EBM. For example, the feasibility of high-quality RCTs on the effectiveness of mitigation measures is questionable. Perhaps more important is the problem of extrapolability and generalizability. This problem normally affects RCTs, but is particularly grave in the COVID-19 context, where outcomes of an intervention conducted in one social and cultural context need to be applied in very different contexts (Broadbent & Smart, types of evidence used in policy. We want to introduce an additional line of criticism of evidence-based policy which is particularly significant in this case. At its core, EBM has very specific ideal, namely the exclusion of individual, theory- and value-laden judgments from the research process (Jukola, We think that this debate on evidence is crucial for COVID-19 policy, but so far it has mostly focused on the  Jukola, . The str Jukola, . However Jukola, .This observation about the role of judgements is central with respect to COVID-19 data. Contrary to the EBM view of evidence as a neutral and value-free entity, judgments and assumptions play a crucial role in determining what the data are evidence for Canali, . For insGiven the central role that diverse judgments play in the production and use of evidence, we argue that they should be at the centre of transparent discussions and scrutiny. Debating the types of evidence that are used as a basis for policy is important. But it is not enough and leaves the role of judgments unquestioned. In the current pandemic, we have unfortunately witnessed severe shortcomings and failures of data strategies due to the lack of reliable information on the different types of tests, collection and judgements (Leonelli,


Twenty fifteen marked the year of assessment for the Millennium Development Goals (MDGs). The MDGs that achieved the greatest success were those where evidence-based practice (EBP) interventions were implemented. The ability to practice evidence-based medicine is grounded in the creation of and access to medical literature that synthesizes research findings. The role that global health literature played in the success of the MDGs demonstrates that medical libraries and librarians have a role to play in achieving the Sustainable Development Goals (SDGs).Librarians can hold capacity-building workshops that provide instruction on how to access evidence-based literature and also train health professionals to conduct synthesis research. Research findings conducted by in-country health professionals are more likely to address issues being faced by local communities and will afford the possibility of obtaining the necessary evidence-based answers that can then be used to implement policies to resolve public health issues identified in the SDGs.This paper discusses how an international team of librarians leveraged funding from a Medical Library Association/Librarians without Borders/Elsevier Foundation/Research4Life grant to hold a capacity-building workshop in Zimbabwe and follow-up online trainings. The workshop focused on accessing evidence-based resources and conducting synthesis research. Outcomes included the creation and policy implementation of evidence-based knowledge products in alignment with local needs and galvanizing a multisectoral group of key individuals who have gone on to collaborate toward the vision of creating a Zimbabwe innovation hub. Looking ahead, such grants can be leveraged to conduct capacity-building to support knowledge translation and other local training needs. Twenty fifteen marked the year of assessment for the United Nations' Millennium Development Goals (MDGs). Overall assessment demonstrated that the MDGs that achieved the greatest success were those where evidence-based practice (EBP) interventions were implemented . AlthougAs transition begins to the Sustainable Development Goals (SDGs), persistent obstacles to tackle to ensure successful transfer of knowledge into evidence and practice for LMICs include 1) increasing primary research and synthesis studies specific to health conditions in the developing world, 2) ensuring findings from such studies are presented to policy makers in an understandable manner, and 3) integrating findings into policy and practice in alignment with the sociopolitical and cultural contexts of each country and local communities , 9, 10. The triple helix of innovation is a framework grounded in the idea that “the interaction among university, industry, and government is the key to innovation and growth in a knowledge-based economy” . Omaswa Below we discuss how five librarians from two Zimbabwean and three American institutions were able to leverage funding from a Medical Library Association/Librarians without Borders/Elsevier Foundation/Research4Life (MLA/LWB) grant to conduct a capacity-building workshop in Zimbabwe. The main goal of the workshop was to provide a framework for participants to develop skills in information retrieval and evidence synthesis, using information resources from Research4Life (R4L) programs. Furthermore, it also proved to be instrumental in generating knowledge products that have been implemented into policy in alignment with local needs, and it galvanized a multisectoral group of key individuals who have gone on to collaborate toward the national vision of creating a Zimbabwe innovation hub.We begin with an overview of the development and evolution of R4L programs. We then discuss the implementation and impact of the Zimbabwe capacity-development workshop. We conclude by conceiving how future capacity-building workshops can support knowledge translation by developing local, networked information infrastructures in line with the triple helix of innovation framework to support evidence-based decision making to achieve the SDGs.Access to, and participation in, knowledge production and dissemination is recognized as a catalyst for development within the SDG agenda . EstabliBeyond access to literature, R4L provides a central platform that connects LMICs, and core activities serve to address the tacit aspects of the research/knowledge production cycle that must be in place for relevant evidence to be produced and made accessible to all stakeholders. Over the last few decades, R4L has evolved into “a vital infrastructural input into the development of evidence-based policies and investment priorities that will maximise the chances of the SDGs being realized” . This evR4L programs have been recognized as a catalyst to information access in LMICs –18. RespResources can only add value if end-users are aware of their existence and have the skill set to navigate and extract relevant information from them. Early on, R4L established partnerships with key institutions such as the Medical Library Association (MLA), the Elsevier Foundation, and the Information Training and Outreach Centre for Africa (ITOCA) to develop Training of Trainers (TOT) programs. In addition to generating awareness and training end-users on resource use, initial workshops focused on developing health information literacy, for which there is a continued need as it plays a role in the achievement of SDG-3 . Over thIn 2016, the MLA/LWB initiative was expanded to include microgrants . The graCooperation and partnerships have long been a vital aspect of health information librarianship, playing a role in sharing resources, providing services, and advocating for unmet needs and issues . Global To meet the SDGs, all regions of the world must move the needle to be inclusive of the entire spectrum of phases, from P1 (access to information) to P4 . The establishment of MLA/LWB's microgrants has provided the opportunity to generate ground-level support for capacity-development in three key ways: 1) they support development of a community of trainers that can conduct trainings beyond university settings, 2) they allow latitude for tailored instruction on topics that address local needs, and 3) they are instrumental in galvanizing key individuals from a variety of backgrounds, which is a key element of moving communities into P4.Research by Popoola et al. identified a training need for librarians in Nigeria regarding EBP and systematic review (SR) . MoreoveAccessing evidence-based resources via Research4Life (two days) and Workshop 2: Introduction to conducting systematic reviews, publishing and author resources (three days). The aim of these trainings was to address gaps in knowledge about access to critical information resources for research and EBP and to lay the foundational skills for conducting evidence synthesis using systematic methods.In 2019, the authors were awarded an MLA/LWB grant, which supported the development of two interconnected workshops—Workshop 1: The two in-person trainings were held in July 2019 at the University of Zimbabwe (UoZ) Library. The trainings were free and open to all researchers, clinicians, faculty, students, and library staff, as well as individuals working in the public sector in government agencies and international government organizations. Broad outreach to R4L countries in Africa resulted in seventy-six applicants from a variety of disciplines from Southern and Eastern Africa. Applicants had the option to register for either one or both workshops with the large majority registering for both. Due to limited space, we chose to prioritize those based at Zimbabwean institutions and admitted forty-five participants including researchers, clinicians, ministry staff, and librarians. Ultimately, an average of thirty-seven participants from eight institutions attended all five days of the workshops.The workshops followed the traditional R4L TOT format that includes a combination of lectures followed by considerable hands-on exercises and group work, thereby actively applying learned content to practice in context.Workshop 1 included an overview of the EBP process, as well as a deep dive into the Hinari research portal. Relevant content from AGORA and OARE were also highlighted. The content emphasized development of searching skills for EBP literature in several databases, as well as free online health resources. All instructional content was tailored to emphasize database content and features that support the creation of synthesis research.Workshop 2 provided an introduction to SRs and in-depth training in problem formulation, eligibility criteria, and systematic searching. The authorship module included instruction on citation management and information on publishing from an author's' perspective. A full agenda is available at . All worBased on our past experience teaching SR methods, we understood that teaching this topic without immediate application of the skills or without establishing ongoing support could hinder long-term learning and impact. With this in mind, we designed the SR training to apply learned skills in the context of developing an SR protocol with topics developed by participants in advance of the training. Participants were encouraged to enroll in the program with potential collaborators, including librarians, with the aim of establishing project teams that would carry out SRs beyond the timeframe of the training. For this reason, the focus of the in-person, three-day training was on early-phase aspects of the SR process and protocol development.To support later stages of the projects, a series of webinars was offered synchronously but recorded for later viewing over the following year. These webinars addressed topics such as translating search strategies across databases and using study screening software. A webinar on assessing study quality and risk of bias was also offered and was cotaught by one of the workshop participants, a biostatistician with expertise in research methods. We also offered monthly, remote, drop-in office hours for participants to ask questions related to their ongoing work or other SR projects in which they were involved.The participants in both workshops were highly engaged, and postworkshop assessments indicated substantial impact. In a survey conducted immediately following the workshop, feedback was overwhelmingly positive, with participants indicating that the content was highly relevant and the format effective and engaging. Attendance at the follow-up webinars and online office hours was rather low, possibly due to scheduling challenges given the time zone differences. However, recorded webinars were viewed asynchronously, and several participants noted their usefulness as a resource for ongoing training. A follow-up survey was also conducted six months after the in-person training. Nine participants responded, of which 78% (n=7) indicated that they had used the knowledge gained from the first workshop on Hinari in their conduct of research, and 67% (n=6) specified that they had trained others on the use of Hinari. Regarding the SR training, 75% of respondents noted that they were currently working on or assisting with an SR six months after the training (n=9). At least one of those resulted in part from connections made at the workshop . See FigBeyond skills training and SR production, other impacts have been noted. The workshops enabled UoZ's 2019–2025 strategic plan , in partOverall, the program addressed key pillars of research capacity-building  in line We cannot draw conclusions regarding the impact of this workshop on achieving the SDGs; however, this collaboration has demonstrated that librarians can support access to evidence-based literature, promotion of health literacy, creation of local knowledge, implementation of evidence into policy, and development of a networked infrastructure that can work toward bridging the communication gaps between key institutions identified in the triple helix model .With the strong interest in synthesis research in LMICs ,34, the To build IKT capacity, professionals need to be educated in the fundamentals and application of KT ,35. AlthLibrarians can leverage small- and medium-sized grants, like the MLA/LWB microgrants, to hold capacity-building workshops to break down barriers around access to, generation of, and dissemination of scientific knowledge required to achieve the SDGs. Workshops can focus on developing skills around database searching, evidence synthesis creation, KT, and more. Moreover, the workshops provide the opportunity to develop multisectoral networks to collectively work toward resolution of regionally relevant, high-priority issues. As part of such multisectoral teams, librarians have the ability to function as discipline-neutral knowledge brokers that can facilitate understanding of barriers faced by actors within triple helix institutions . Overall, librarian-specific skills of training, finding, analyzing, synthesizing, organizing, storing, and disseminating high-quality evidence can contribute to reducing the knowledge translation gap by implementing research findings into policy and practice in a timely manner to resolve global health issues.


Poor oral health increases the risk of aspiration pneumonia for older people. This is due primarily to six pathogens found in the mouth: five bacteria and one fungus. With a cohort of older people who were dependent on others for their oral care, we analyzed the load and type of bacteria and fungi from swabs of cheek, gum, and tongue mucosa. There were no significant differences between the three sites for load of bacteria (H (2) = .89; p = .64); there were significant differences between the sites for type of bacteria  = 11.97; p <.001) with the tongue showing the greatest diversity. There were no significant differences between the three sites for load (H (2) = 2.94; p = .23) or type  = .46; p = .63) of fungi. We then investigated the effect of regular compared to evidence-based oral care over a six-week period, and whether evidence-based oral care could significantly reduce the absolute count of the six oral pathogens specifically related to aspiration pneumonia. Participants self-selected into Regular Care (n = 10) and Evidence-based Care (n = 17) Groups. Evidence-based oral care resulted in significant decreases (p = .02 to p < .001) in the load of four potentially pathogenic bacterial species, including E. coli, gut-based bacteria, and in an increased load of Lactobacillus reuteri, a host-protective normal flora in the mouth, compared to baseline. There were no significant differences between groups for the abundance and type of fungi.


Arabidopsis arenosa. Thus far, A. arenosa has been known as a model species for autotetraploidy studies because, apart from diploid individuals, there are also tetraploid populations, which is a unique feature of this Arabidopsis species. In addition, A arenosa has often been reported in heavy metal-contaminated sites, where it occurs together with a closely related species A. halleri, a model plant hyperaccumulator of Cd and Zn. Recent studies have shown that several populations of A. arenosa also exhibit Cd and Zn hyperaccumulation. However, it is assumed that the mechanism of hyperaccumulation differs between these two Arabidopsis species. Nevertheless, this phenomenon is still not fully understood, and thorough research is needed. In this paper, we summarize the current state of knowledge regarding research on A. arenosa.The following review article collects information on the plant species  Arabidopsis arenosa, previously known as Cardaminopsis arenosa, is a species of flowering plants in the family Brassicaceae, which includes two subspecies: A. arenosa ssp. arenosa and A. arenosa ssp. borbasii [A. arenosa is a model plant species used to study the natural phenomenon of autopolyploidyzation, which means the duplication of the whole genome within one species, in contrast to allopolyploids, which are the result of genome duplication via interspecies hybridisation. A. arenosa is more closely related to its diploid sister taxa A. lyrata and to A. halleri , than to A. thaliana. Although A. arenosa and A. halleri are closely related, studies which compare both species are still scarce [A. halleri, in which only diploid forms (2n = 2C = 16) were found [borbasii ,2. A. arl scarce ,4,5. A dre found ,8,9.A. arenosa grows in subfertile soils. It has been observed in sandy areas, dry grasslands and roadsides. Plants of this species are present in many sites in Europe; however, their location differs depending on the level of ploidy, because tetraploid forms were noted in Slovenia, France and Belgium to the west and north of the Carpathians, while diploid forms have been found in South-East Europe, the Balkan Peninsula and northern Hungary. Moreover, the Carpathian mountain arch, in particular the western Carpathians, is one of the two contact zones where both diploid and tetraploid populations co-exist. The second contact zone of both cytotypes is in the Slovenian Forealps [A. arenosa, similarly to A. halleri, is a pseudo-metallophyte [A. arenosa are presented in Forealps ,10,11,12llophyte ,14,15,16llophyte ,4,17,18.llophyte ,20,21,22A. arenosa is a biennial or short-lived perennial herb. The leaves are arranged in a rosette at the ground level, and no runners form from the rosette. The shape of the leaf blade is obovate to oblanceolate, pinnatifid to lyrate-pinnatifid and with three to eleven lateral lobes on each side. The stems of this plant species are erect, simple, or with few or more branches from the base. A. arenosa produces tiny flowers whose petals are white to lavender, obovate, obtuse or cut at the apex [A. arenosa are always smooth and raised up, in contrast to A. halleri, in which a narrowing reflecting the seeds occurs  genes, which encode core components of the chromosome axis and present a strong signature of adaptive evolution focused on a mutation that changes a single amino acid [SISTER CHROMATID COHESION2 (SCC2), responsible for encoding the adherin loading cohesin during meiosis [STRUCTURAL MAINTENANCE OF CHROMOSOMES 3, 5 and 6 , genes related to meiosis, which show signatures of selective sweeps [terility ,24,25. Thomologs ,12,26. Agulation ,12,23,26ino acid ,12,24. O meiosis , as welle sweeps . Moreovee sweeps ,30.A. arenosa inhabit sites polluted by human activities, going beyond the natural areas inhabited by diploid ancestors [The ability to duplicate the whole genome, and thus the ability of autotetraploidyzation, has certain consequences. Results of a recent study support the possibility that it is possible to overcome the adaptation obstacles caused by reduced selection efficiency, due to increased mutational input ,32. Thisncestors ,29,33.Arabidopsis arenosa is considered to be a pseudo-metallophyte, that is, a plant species that inhabits both metalliferous and non-metalliferous sites [A. arenosa to hyperaccumulate Zn [Nocceaea caerulescens, also from the family Brassicaceae, in 1865 [Sedum alfredii, Sedum plumbizincicola) [A. arenosa compared to Plantago lanceolata and Plantago major grown in the metal-contaminated soils in situ. Moreover, in A. arenosa, the translocation factor  was above 1 for Cd and Zn, which suggested the hyperaccumulation of both metals [A. arenosa to hyperaccumulate Cd and Zn [A. arenosa, as this feature for Zn has been proven in five out of six studied metallicolous populations. In contrast, Cd hyperaccumulation was found only in three metallicolous populations [A. arenosa from southern Poland to grow in HM-contaminated soil was shown. However, the capability for the hyperaccumulation of Zn or Cd by both populations was not presented [us sites ,18,22. Fus sites ,34. Neveulate Zn , accordiulate Zn . The terulate Zn ,37,38,39 in 1865 . Current in 1865 ,41,42,43ncicola) ,45,46. Incicola)  showed th metals . Recent d and Zn . In thisulations . In addiA. arenosa in various habitats show specific morphological features. For example, the length of the leaves of plants grown on a copper (Cu) mining heap was 2.5 times smaller than the leaves of plants grown in non-contaminated soil. By contrast, the length of the roots of the seedlings from the heap was remarkably longer compared with the plants from the reference site [A. arenosa population growing on a Zn/Pb waste heap had smaller size, thicker and narrower leaves, with fewer trichomes. Moreover, the root test showed a higher tolerance to Cd, Zn and Pb for the population from the heap compared to the reference population [A. arenosa tetraploid plants growing in hydroponic solution without HMs displayed higher above-ground biomass compared to the A. halleri plants [A. arenosa [A. arenosa and A. halleri [S. alfredii [Populations of nce site ,48. Simipulation . On the i plants . However arenosa . Root bi arenosa . Similaralfredii .A. arenosa in situ demonstrated the adaptability and high level of tolerance of the metallicolous population to HM. Nevertheless, NM populations had better PSII energy fluxes parameters compared to the M populations. However, the values of the parameters studied for a population from the extremely polluted area were closer to the NM populations than to the most M populations [A. arenosa plants from highly polluted sites in Piekary Śląkie (Poland), the exceptionally high resistance of the photosynthetic apparatus to metals was found. The photosynthesis parameters were similar to those in plants from the reference sites. However, such high resistance is not observed in all populations from metalliferous sites [N. caerulescens, Cd and Zn were accumulated mostly in the vacuoles of epidermal cells; in consequence, the metals were non-toxic for PSII. Exposure to 800 μM Zn or 40 μM Cd in a hydroponic experiment increased Ca2+ translocation to the above-ground parts and increased Fe3+ uptake as a PSII photoprotective mechanism [A. halleri, but HMs were accumulated in the vacuoles of leaves’ parenchyma [A. halleri treated with Cd, who found that Cd is mainly accumulated in the veins and reduces the distribution of Fe and Zn from the veins. However, no effect on the distribution of Ca was found. Thus, the disturbance in the leaf nutrient homeostasis after Cd treatment could be the main factor behind the progressive inhibition of the PSII reaction centers and the decrease in quantum yield of the electron transport [A. arenosa leaves. It has been shown that the metallicolous population of A. arenosa exhibit similar values of chlorophyll a fluorescence to the metallicolous A. halleri population: the HM hyperaccumulator. A significantly higher chlorophyll content index in the metallicolous and non-metallicolous A. arenosa populations compared to the A. halleri populations was also found. Moreover, the higher content of this pigment in A. arenosa compared to the metallicolous A. halleri population may indicate a better physiological status of this A. arenosa population [In general, photosynthesis in hyperaccumulator plants has been seldom investigated. As a result, the resistance of photosynthetic apparatus to the toxic effect of metals in this group of plants is poorly understood ,51,52, iulations . This maus sites . In N. cechanism . A similrenchyma . A diffepulation .A. thaliana that anthocyanins play a major role in protecting against metal stresses [Alyssum montanum. Furthermore, the accumulation of flavonols in leaves was a characteristic reaction of M-ecotypes of A. montanum during HM treatment [A. arenosa populations from metalliferous rather than non-metalliferous sites  and shoot (ZIF1 and YSL3), as well as Cd vacuolar sequestration (HMA3) [A. halleri are associated with the differential accumulation of these metals in shoots [A. halleri and N. caerulescens [A. halleri, HMA4 occurs in three copies and shows higher expression (four- to ten-fold) compared to HMA4 in A. thaliana. In A. halleri, this higher expression of HMA4 is crucial for the process of hyperaccumulation and hypertolerance [A. halleri in vascular tissues. This pump also provides a metal exclusion from sensitive tissues such as the root tip [HMA4 has been demonstrated not only for A. halleri but also for other hyperaccumulators, including N. caerulescens, S. alfredii and S. plumbizincola [A. halleri shoots and S. alfredi shoots and roots [A. halleri, the presence of five copies of MTP1 gene was found, which is strongly expressed both in shoots and roots [N. caerulescens and S. alfredii [A halleri, a higher expression level of HMA3 was detected in the mesophyll, whereas N. caerulescens had higher expression in the bundle sheath of the veins [S. alfredii and S. plumbizincola [NRAMP1, NRAMP3, NRAMP4, and NRAMP5 has been detected in A. halleri and N. caerulescens [A. halleri, the higher expression of the transporter CAX1 (cation-exchanger 1) also seems to be responsible for Cd hypertolerance [Despite the growing scientific interest in  halleri ,22,35,66 halleri ,46,67. Zn (HMA3) . IRT1 , AT1G71210 (pentatricopeptide repeat (PPR) superfamily protein), AXY8 , NRPC2 (nuclear RNA polymerase C2), and AT4G19050 (NB-ARC domain-containing disease resistance protein). Surprisingly, none of these genes are responsible for metal uptake or tolerance. Thus, it is evident that further research should be conducted on genes exhibiting selective sweep signatures as well as those connected with metal uptake and tolerance  isolated from A. arenosa from the mine wastelands. The studies on plants treated with metals showed several important beneficial aspects of fungus presence, such as improving the water and phosphorus status. The fungus also increased the fresh weight almost two-fold compared with the control. The plants inoculated with Mucor sp. and growing on the mine dump substrate had a three times higher N content in the shoots than the uninoculated plants [A. arenosa and A. halleri by denaturing gradient gel electrophoresis (PCR-DGGE). It was found that biodiversity indices in metal-contaminated soil differed between both species and was lower in the A. halleri rhizosphere [Moreover, studies were conducted on the interaction of the endophytic fungus (d plants ,113. Addd plants . Furtherzosphere .Arabidopsis arenosa has gained interest among scientists for its unique feature of duplicating the whole genome of autotetraploid populations while also existing as a diploid form. Due to this feature, this species has become a model plant for research on the autopolyploidization process. However, this plant species is also able to grow and develop on soils highly contaminated with HM. Moreover, the hyperaccumulation of Zn and Cd has been found recently in several tetraploid populations of A. arenosa from Poland. Further investigations on the mechanisms of hyperaccumulation of both metals in this plant species are necessary, particularly in countries other than Poland. At present, only tetraploid populations are known as hyperaccumulators. Thus, it is necessary to find out if diploid populations can also grow on metal-contaminated soils and hyperaccumulate Zn and/or Cd. Although A. arenosa is well known as a pseudo-metallophyte, our knowledge on the mechanism of metal uptake and tolerance in this plant species is very poor, in contrast to A. halleri or N. caerulescens. Thus far, to the best of our knowledge, no research studies have been published for A. arenosa, which present the expression level of such genes or gene families as HMA2, HMA3, HMA4, ZIP, NRAMP and MTP, which are crucial for metal tolerance and/or hyperaccumulation. Furthermore, it was found that the tetraploid population from the non-metalliferous site had considerably lower resistance to Cd compared to the tetraploid metallicolous population. These results show that tetraploidy in A. arenosa is not sufficient for high tolerance to metal toxicity. Thus, investigations are necessary to find out if metal hyperaccumulation and/or tolerance are connected with higher specific gene copy numbers, as shown for A. halleri or N. caerulescens. The above knowledge can be further exploited in high biomass plant species that could be used for phytoremediation or in the production of fortified food.


There is a lack of literature on short latency period (SLP) in twin pregnancies with preterm premature rupture of membranes (PPROM). Thus, the aim of this study was to identify the clinical factors and perinatal outcomes associated with SLP in twin pregnancies with PPROM and to establish a predictive model to identify SLP.Twin pregnancies with PPROM between 24 0/7 and 33 6/7 weeks were included and a retrospective analysis was performed. Patients were divided into two groups based on the latency period after PPROM: Group 1 ≤24 h (defined as SLP) and Group 2 >24 h , the clinical factors and perinatal outcomes were compared between the two groups. Binary logistic regression and receiver operating characteristic curve analyses were used to identify the independent clinical factors associated with latency period after PPROM and assess the predictive accuracy for SLP.P = 0.038), presence of uterine contractions (P < 0.001), Bishop score > 4 (P = 0.030), serum procalcitonin levels ≥0.05 ng/mL upon admission, and absence of use of tocolytic agents (P < 0.001) were significant independent predictors of a SLP. A predictive model developed using these predictors had an area under the curve (AUC) of 0.838, and the presence of uterine contractions alone had an AUC of = 0.711.98 and 92 pregnant women had short and long latency period, respectively. Prolonged latency significantly increased the occurrence of chorioamnionitis. Neonatal outcomes were not affected by latency duration after PPROM. Binary regression analysis revealed that higher gestational age (GA) at PPROM (Uterine contraction was the most important prognosticator for a SLP. A latency period of >24 h was associated with chorioamnionitis, but adverse neonatal outcomes were not observed. Preterm premature rupture of membranes (PPROM) occurs in 3% of all pregnancies, and approximately one-third of premature births are caused by or are related to PPROM, which is an important factor in neonatal morbidity and mortality –4. With The latency period is defined as the time from rupture of membranes to delivery. There are many factors that affect the latency period after PPROM, but no risk factors have been identified, including the GA at PPROM, multiple pregnancies, oligohydramnios, cervical length, use of prophylactic antibiotics, and tocolysis –10. MultHowever, to date, there is a lack of information in the literature on the early recognition of short latency period (SLP) in twin pregnancies with PPROM. We have hardly found any research on infection indicators, such as serum inflammatory markers and vaginal microorganism culture that affected the latency period in twin pregnancies with PPROM.In the present study, we aimed to identify clinical factors and perinatal outcomes of latency period within 24 h in twin pregnancies with PPROM before 34 weeks. Most previous studies were committed to exploring the clinical characteristics of singleton pregnancies, while ignoring the urgent healthcare needs of women with twin pregnancies. Identifying the significant predictors of a SLP in twin pregnancies with PPROM will provide a more appropriate clinical management and personalized treatment. Physicians could provide consultations, strengthen prenatal monitoring, and perform intrauterine transfers in time. The main purpose of this study was to identify the clinical factors associated with a SLP, to prolong the latency period, and to improve the perinatal outcomes in twin pregnancies with PPROM.This retrospective study reviewed the medical records of twin pregnant women with PPROM between 24 0/7 and 33 6/7 weeks who were admitted to the Obstetrics Department at Chongqing Health Center for Women and Children, a single tertiary referral center in Chongqing, China, from 1 January 2017 to 31 April 2021. We excluded women with any of the following conditions: at least one intrauterine death on admission, couples who gave up the pregnancy for induced labor, and with complications of monochorionic-diamniotic twins . The study was approved by the Ethics Committee of Chongqing Health Center for Women and children.Rupture of membranes occurred at <37 weeks of gestation before labor. Diagnosis was based on pregnant women with a history of vaginal discharge, and on sterile speculum examination, leakage of amniotic fluid from the cervical os, or pooling of amniotic fluid in the posterior vaginal vault. If the characteristic findings were not significant, we performed an ultrasound examination to assess amniotic fluid volume, measured insulin-like growth factor binding protein-1, or conducted fern tests to assist in the diagnosis.The GA was determined based on the first day of the woman's last menstruation and the crown-rump length measured by ultrasound in early pregnancy. GA was also estimated based on the date of embryo transfer when the pregnancy was conceived through assisted reproductive technology (ART).9/L, or the uterus is irritated with presence of uterine tenderness.Maternal body temperature ≥38°C accompanied by any of the following criteria can be diagnosed with clinical chorioamnionitis: malodorous vaginal discharge, fetal tachycardia (baseline ≥160 beats per minute), maternal tachycardia (≥110 beats per minute), maternal peripheral blood leukocyte count ≥ 15 × 10All patients of expectant management received dexamethasone (four intramuscular doses of 6 mg 12 h apart) for maturation of the fetal lungs and intravenous broad-spectrum prophylaxis  for 48 h, followed by oral amoxicillin and erythromycin for 5 days to prevent infection. Magnesium sulfate was routinely administered for fetal neuroprotective effects. Nifedipine, indomethacin, atosiban, and ritodrine were used as tocolytic agents depending on the status of the pregnant woman.The status of the mother and fetus was closely monitored until delivery. Pregnant women underwent a vaginal examination on admission to obtain the Bishop score, and secretions were taken for microbial and group B streptococcus (GBS) cultures. The patients were checked daily by obstetricians. Maternal serum inflammatory markers, specifically blood routine examination, and C-reactive protein (CRP) and procalcitonin (PCT) levels were checked every 3 days. Ultrasound scans were performed every 3–4 days to evaluate the amniotic fluid volume and the status of the fetus. A single deepest pocket ≤ 2 cm was considered oligohydramnios. Non-stress test was initiated at 32 weeks daily to assess the status of the fetus and earlier GA for high risk patients.When clinical chorioamnionitis was diagnosed, if premature birth was inevitable, if there were indications for delivery of the mother and/or fetus, or if GA reached 34 weeks, the pregnancy was terminated by induction of labor or cesarean section depending on the patient's desire, obstetric history and fetal status.2), mode of conception, chorionicity, GA at PPROM, maternal inflammatory markers  before the administration of antibiotics or steroids, Bishop score [refer to the original text for  Maternal parameters including the age, working condition, parity, history of preterm birth, and history of PPROM; (2) Information regarding current pregnancy including prepregnancy body mass index  and 95 % confidence intervals (CI) were calculated. Receiver operating characteristic (ROC) curves were used to assess the predictive accuracy of the SLP with twin pregnancies complicated by PPROM. P ≤ 0.050 was considered as statistically significant.Data were analyzed using SPSS version 25.0 . Descriptive statistics were used to analyse the patients' clinical factors and perinatal outcomes, and the chi-squared test or Fisher's exact test was used to analyse categorical variables. After assessing normality, the statistical significance of the continuous variables was assessed using the Student's A total of 190 women with twin pregnancies (including 164 dichorionic diamniotic twins and 26 monochorionic diamniotic twins) with PPROM between 24 0/7 weeks and 33 6/7 weeks were included in the final analysis, of which 98 (51.6%) patients were in Group 1 and 92 patients (48.4 %) in Group 2. The mean maternal age of these patients was 30.3 ± 3.7 years. The median GA at PPROM was 32 1/7 weeks (Q1:30 0/7 weeks to Q3:33 1/7 weeks), and the median latency period was 22 hours (Q1:7 to Q3:71 h).in-vitro fertilization conception, chorionicity, prepregnancy BMI, maternal inflammatory markers (except PCT), the positive rate of vaginal microbiological and GBS, and presence of pregnancy complications were similar between the two groups. Pregnant women with a SLP were more likely to have a high GA at PPROM, a Bishop score >4, serum PCT levels ≥0.05 ng/mL, uterine contractions upon admission, and not received tocolytic agents.The clinical factors of short and long latency periods are described in P = 0.020), and presence of uterine contraction (p < 0.001) demonstrated a significant independent association with a SLP. We also found that a Bishop score > 4 lowered the OR of the long latency period, and the use of tocolytic agents increased the OR of the SLP. Our model did not demonstrate an independent association of PCT ≥0.05 ng/mL with SLP.The final predictive model had five main factors, as listed in The predictive accuracy of the final model was assessed using the area under the AUC curve. The final model using these independent variables had an AUC of 0.838, as shown in p = 0.02). Twenty-three fetuses (6.1%) experienced intrauterine demise or neonatal death in total, independent of the latency period. All statistical neonatal outcomes (except birth weight) between the two groups were not statistically significant.We examined differences in perinatal outcomes according to latency period . A latenRecently, substantial studies have highlighted the clinical factors associated with a LLP  among singleton pregnancies with PPROM , 10. TheThe standpoint that PPROM in twin pregnancies tends to have a SLP than singleton pregnancies is widely recognized , 12–14. When controlling for other confounding factors, we identified four significant predictors of a SLP in a multivariate analysis. The predictive model  may adequately evaluate SLP at admission to change traditional treatments that might eventually improve perinatal outcomes. In summary, there are multiple avenues to experience a SLP, but the strongest factor may be the presence of uterine contractions , while early and high doses of tocolytic agents may prolong the latency period. A similar correlation was found in the study by Phupong et al., who found that prophylactic tocolysis was a major factor associated with a latency period ≥2 days after PPROM . Some scRecent data indicated that cervical length and cervical dilation at admission were inversely associated with the latency period in twin preganncies complicated by PPROM , 19. HowIntraamniotic infection has been associated with the initiation and progression of PPROM . High maOur study demonstrates that the occurrence of chorioamnionitis is related to prolonged latency. An inseparable relationship between PPROM and chorioamnionitis has been confirmed in numerous studies , 24, 25.We found that prolonged latency was unrelated to perinatal outcomes, Unlike chorioamnionitis, neonatal sepsis was not related to the duration of latency; this finding has also been confirmed by several other studies –29. Two Indeed, some study population have been reported in our previous article , and theThe present study provides evidence to identify a SLP according to clinical factors. Our study showed that a high GA at PPROM, presence of uterine contractions, Bishop score>4, and absence of use of tocolytic agents were associated with a shortened latency period in twin pregnancies with PPROM. The most important prognosticator was the presence of uterine contraction. A latency period >24 h was associated with chorioamnionitis, but adverse neonatal outcomes were not observed. Accordingly, the data presented in this study can be used by obstetricians to provide consultation and provide predict the latency period for the ease of intrauterine transfer and personalized treatment. Additionally, more studies are needed to achieve a reliable and feasible model for clinically useful calculations.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by The Ethics Committee of Chongqing Health Center for Women and Children. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.SZ, LM, and LW designed the study. SZ and LM drafted the manuscript. XM and QQ conducted the statistical analysis. YY and SZ collected the data. LW and WZ revised the manuscript. All authors have read and approved the final study.This study was founded by Chongqing Health Commission and Science and Technology Bureau (2019GDRC013). The role of this funding is in editing the manuscript and article-processing charge.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.