Background: The vast majority (90%) of the world's adolescents aged 10–19 live in low- and middle-income countries (LMICs); and in those resource-limited settings, girls face distinct challenges across multiple health, social, and economic domains. Gender equality and girls' empowerment are key goals in their own right and are central to all other development goals. Digital literacy is a great enabler for the empowerment of young girls. This systematic review aims to assess the range and nature of digital literacy interventions implemented to empower adolescent girls in LMICs and identify evidence about adolescent girls' access and use of digital technologies in LMICs.Methods: We conducted a systematic review of studies following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) standards for systematic reviews. Two reviewers selected studies, conducted quality assessments, and extracted data by using standard forms. The collected data include the design of the study, type of digital literacy intervention, target audience, intervention received, intervention reach, data analysis, and study outcomes. The review is registered with PROSPERO (CRD42020216756).Results: Thirty-five studies met the eligibility for inclusion and of those, 11 were experimental studies , 11 were cross-sectional/descriptive studies, seven studies used a mixed-method approach, and six were qualitative studies on digital literacy interventions to empower young girls in LMICs. The majority of digital literacy interventions were designed and implemented to improve sexual and reproductive health rights and decision-making of adolescent girls in LMICs (n = 33). Only three papers reported the use of digital media for health-related information and decision making, while only one reported on educational and social empowerment.Discussion: Our findings suggest that digital literacy interventions such as mobile phones, mobile health tools, media exposure, access to the internet, internet-based educational strategies, social media exposure are effective to empower adolescent girls to access health services and information and also enhance the access to educational resources. However, we found inconclusive evidence on the effectiveness of digital literacy to enhance girls' access to financial services and economic empowerment. More rigorous studies with long-term follow-ups to assess the effectiveness of such interventions to empower adolescent girls in LMICs are urgently needed. Digital literacy refers to the individual's ability to use digital platforms and resources to find, evaluate, and obtain information . The effDigital literacy is critical for children's and young people's development across a wide range of areas. These include engagement in online education, both formal and informal learning, access to critical information and support related to health and well-being, and searching for employment, career information, and entrepreneurship opportunities. This holds great importance for young girls and women's empowerment especially in settings where the women lag behind the men and lack the necessities to live . In addiThe use of digital technology also promotes accessing and utilizing sexual and reproductive health (SRH) services among young girls. Digital communication opens the gate and offers wider access to SRH information and services such as puberty, menstruation, bodily autonomy, healthy relationships, contraception etc. . AdolescGlobally, ~1.2 billion people are under the age of 10–19 years, 90% of whom live in LMICs . AdolescThis systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines , and incStudies were included on adolescent girls aged 10–19 years living in LMICs defined by the World Bank . The stuThe primary outcome of the study included access to digital technologies by adolescent girls in LMICs, and improved decision-making for own health, continuing education, work, marriage, pregnancy, etc. The secondary outcome of the study included improved SRH status i.e., decrease in early marriages, teenage pregnancies, uptake of contraceptive methods, and improvements in overall health status, etc.The search strategy was made with the research librarian from the University of Alberta (SC). Databases were searched from inception to December 2020. The databases that were used for running the search strategy included. PubMed, Ovid MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL), EPOC systematic review database, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database, HealthStar, EMBASE (Excerpta Medica), CINAHL , PsycINFO , WHO library and other relevant websites  and Sociological Abstracts . To miniCOVIDENCE software was used for streamlining the screening process of systematic review from the stage of title and abstract screening and full-text screening . Two indData were extracted from the included studies such as the name of the author, year of publication, study design, the objective of the paper, target population, sample size, intervention type, intervention mode of delivery, outcomes, and key findings . One revThe methodological quality of all the included studies was assessed by using the Mixed Methods Appraisal Tool (MMAT tool). The tool provided ground to assess the methodological quality of five types of study designs including qualitative studies, randomized-controlled trials, non-randomized cohort studies, quantitative descriptive studies, and mixed-method studies .A tailored approach to synthesize the data was employed by utilizing an evidence table , 2. A naThe initial search retrieved a total of 1,283 articles. After removing duplicates and articles in other languages and reviewing abstracts with respect to the inclusion criteria, a total of 987 studies were considered relevant. Following a full-text review and consultation among the authors, 35 articles were included in the final review and analysis using the PRISMA diagram  22). Fi. Fi22). n = 6) (n = 2) (n = 3) (n = 20)  –31, foll n = 2) , 33, bef (n = 3) –36; whil (n = 3) –47, seve (n = 3) –54, and  (n = 3) –60. Samp(n = 20) –58, 60, (n = 20) , 52, 59,(n = 20) , 38, 54,(n = 20) . The met , 33, be(n = 20) . The majVarious digital strategies and interventions were used to empower adolescent girls such as text messages, mHealth, mass media, website development, and mobile-based games. We thematically analyzed and put up the major findings under the thematic areas of digital literacy to empower adolescent girls in LMICs. The studies included were categorized under three headings: digital literacy for sexual and reproductive health and rights empowerment, digital literacy to promote health information and decision making, digital literacy for social and educational empowerment.n = 33) through digital health literacy (www.youthhood.com.cn) that offered SRH knowledge, service information, counseling, and discussion. Participants in the intervention group were only allowed to access the website (p < 0.0001). The intervention also had a positive influence on their attitudes toward sex-related issues (p < 0.05) and toward providing contraceptive service for unmarried people. Similarly, Nik Farid et al. used (MyCAP) website for online SRH education to improve SRH knowledge among Malaysian young people , and mobile app are also identified as effective tools to increase SRH knowledge of adolescent girls , 49, 59,Guerrero et al. conducted participatory research and developed the content for an SMS platform jointly with adolescents and youth in three regions in Peru as part of the ARMADILLO (Adolescent/Youth Reproductive Mobile Access and Delivery Initiative for Love and Life Outcomes) Study. The study reported that adolescents prefer to receive SRH information on various topics such as STI/HIV, SRH rights and policies, pregnancy, and contraceptives through SMS .n = 12) identified that the internet is the main source of information for many adolescents and youth in LMICs. Studies reported that SRH information available on the internet increased the SRH knowledge and improved the attitudes toward SRH of participants . The study identified that the game generated interaction and engagement with parents, siblings, and friends and served as a catalyst for children to act as advocates for health decisions about sex, both within the family and beyond  do not own a cell phone in Burkina Faso . Bajoga d beyond . Studiesd beyond , 52. In d beyond .Only three studies reported the use of digital literacy for health information and healthcare decision-making , 52, 57.We found only one study that explored the impact of digital literacy on adolescents' social and educational empowerment . The stuThis review has identified 35 studies that have assessed the digital literacy interventions and reported outcomes broadly as SRH empowerment, overall health information and decision-making empowerment, and social and educational empowerment.The findings from this systematic review highlighted that the use of internet and mHealth interventions were found to be effective in improving the knowledge, attitude, and practice toward SRH topics including HIV/STI prevention, and improved uptake of contraception amongst adolescents. Social media especially Facebook, Google, WhatsApp, and YouTube are key online resources for adolescent girls and a great source of information on SRH related topics. Similarly, SMS is a medium for imparting knowledge as well. The odds for accessing the information on SRH topics were significantly higher among girls who owned a mobile phone.These findings are in concordance with the other reviews, which suggest, that mobile phone approaches; including text messages, in particular, provide feasible and potential effective medium to increase SRH education and ensure safe sexual behaviors among adolescents , 62. A CAnother important aspect gained from this systematic review is that the use of digital media by adolescent girls not only promotes SRH related outcomes but also improves general well-being and healthcare decision-making. Young girls also access information about the dangers of self-medication, use of disposable syringes for injection, information about causes of hepatitis B and C, and regarding garbage disposal through the digital medium. Similar behavior was seen in school-going adolescent children that they use the internet and other broadband applications for accessing healthcare information. They also used emails to ask for health-related information from the physicians if they had any concerns and also initiate conversations with their teachers pertinent to health-related information .The review also highlighted the effect of digital literacy on social and educational empowerment amongst adolescent girls. These educational attributes were in general but only limited to academic performances, improved self-esteem, and better relationships with significant others. These findings resembled with one of the studies conducted to evaluate the role of digital literacy on performance tests and showed a positive relationship between digital literacy and academic scores. However, after adjusting the confounders, the results were not the same . These cWhile on one hand, digital literacy contributes toward the empowerment of the adolescent population, it also directs them in a negative direction where the youth engage themselves in acts including online harassment, sexual exploitation , cyberbuThis systematic review is the first of its kind that has aimed at identifying the effectiveness of digital literacy for empowering girls in LMICs. The findings not only highlighted empowerment in SRH but also gave an insight into the role of digital literacy in promoting general health information and the educational and social aspects. However, there is a need to understand the challenges of data privacy, technological literacy, linguistic competency, and phone access to address the barriers impeding access to digital technology by adolescent girls in LMIC. In addition, a more complete understanding of the role of digital literacy for educational and economic empowerment is required, to strengthen the evidence base in overlooked areas.While the methodological assessment of the included studies highlighted moderate to the high quality of evidence for interventional studies and poor to the high quality of evidence for observational studies, there were also some limitations. The majority of the included studies were based on cross-sectional/observational study designs. Though these studies help in gauging a snapshot of the exposure and the outcome at a particular time, they do not allow to identify a temporal relationship. Thus, the cross-sectional studies cannot tell the long-term impact or effectiveness of digital literacy on empowering adolescent girls in LMICs. In addition, the interventional studies were not homogenous in terms of intervention used and outcomes reported and therefore pooled estimates and meta-analysis of the could not be performed.In the modern era where everything is more digitalized and technology-related, the inequalities based on gender in accessing these are a real concern, especially for girls from disadvantaged settings such as LMICs. The role of digital literacy in empowering adolescent girls living in LMICs is an emerging idea. It not only plays a role in improving the SRH outcomes but also contributes to improving health-related and educational outcomes and decision-making. The findings from this review can be used as a ground for developing new evidence-informed interventions, policies, and practices for girls in LMICs.The original contributions presented in the study are included in the article/SM and ZL participated in the study conception and design. SC searched the articles. SM, ZL, and KR participated in analyses. SM and KR performed the quality assessment and wrote a first draft of the manuscript. ZL commented on this draft and performed critical revisions. All authors have read and approved the manuscript.This project was supported by University of Alberta, Faculty of Nursing VPR SIG Funding 2020.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.The reviewer AK declared a shared affiliation with one of the authors, ZL, to the handling editor at the time of review.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The future of Autonomous Vehicles (AVs) will experience a breakthrough when collective intelligence is employed through decentralized cooperative systems. A system capable of controlling all AVs crossing urban intersections, considering the state of all vehicles and users, will be able to improve vehicular flow and end accidents. This type of system is known as Autonomous Intersection Management (AIM). AIM has been discussed in different articles, but most of them have not considered the communication latency between the AV and the Intersection Manager (IM). Due to the lack of works studying the impact that the communication network can have on the decentralized control of AVs by AIMs, this paper presents a novel latency-aware deep reinforcement learning-based AIM for the 5G communication network, called AIM5LA. AIM5LA is the first AIM that considers the inherent latency of the 5G communication network to adapt the control of AVs using Multi-Agent Deep Reinforcement Learning (MADRL), thus obtaining a robust and resilient multi-agent control policy. Beyond considering the latency history experienced, AIM5LA predicts future latency behavior to provide enhanced security and improve traffic flow. The results demonstrate huge safety improvements compared to other AIMs, eliminating collisions (on average from 27 to 0). Further, AIM5LA provides comparable results in other metrics, such as travel time and intersection waiting time, while guaranteeing to be collision-free, unlike the other AIMs. Finally, compared to other traffic light-based control systems, AIM5LA can reduce waiting time by more than 99% and time loss by more than 95%. Autonomous Vehicles (AVs) are becoming an integral part of our society due in part to recent advances in Artificial Intelligence (AI) and technology improvements, which enable safer, easier, and more reliable travel, along with a large reduction in the number of injuries and fatalities caused by human error. AVs are designed to drive themselves on highways and freeways with great ease, but urban roads are a challenge yet to be solved. Therefore, the next step is to develop AVs that are able to drive in challenging traffic conditions, such as busy streets with pedestrians, cyclists, emergency vehicles, traffic lights, multi-signals, intersections, etc., and make them capable of adapting to different traffic conditions and user behaviors, thus providing greater safety for all traffic actors.An approach to addressing the challenge of urban traffic is using Autonomous Intersection Management (AIM) . An AIM In this context, the control of AVs using AIM requires knowledge of the state of all AVs to be controlled to make the right decisions, as well as AVs cooperating to achieve the same goals. A cooperative control system must be aware of the state of all AVs at the intersection and adapt its strategy in a time-limited manner. In addition, it must have the necessary foresight to be able to anticipate potential problems and cope with uncertainties. To the authors’ knowledge, most research studies on cooperative control in AIM focus on the design of control strategies, and do not consider  the communication latencies inherent in wireless communication systems between AVs and the IM.Due to the lack of works studying the impact that the communication network can have on vehicle control and safety, this paper presents a novel latency-aware deep reinforcement learning-based AIM used for AV control in the 5G communication network, called AIM5LA. It was decided to use the 5G communication network given the advantages it offers for vehicle control using Ultra Reliable Low Latency Communications (URLLC). This is the first latency-aware AIM trained fully by Multi-Agent Deep Reinforcement Learning (MADRL). When we say it is latency-aware, we mean that AIM5LA adapts the control of the AVs to the inherent latency of the 5G network, thus providing safety and smooth traffic flow. If communication latency were not considered, a small delay in control could cause a vehicle to receive an order later than desired, leading to undesirable situations, including collisions.(i)Taking into account the previous latencies of all AVs using a deep neural network based on a recurrent neural network to encode the latencies of the other AVs;(ii)Predicting the latency that each AV is going to experience in the next timestep, using a Transformer-based deep neural network, to adapt the control of the AVs;(iii)Consider the number of AVs to be controlled simultaneously as an internal parameter to adapt the control according to the number of AVs;(iv)Propose the set of messages as well as the communication protocol for AIM5LA implementation.Although AIM5LA is derived from an AIM system implemented in previous work , AIM5LA The rest of the article remains as follows: In AIMs represent a very suitable approach to solving traffic problems because of the great versatility they offer. They have been extensively studied and have demonstrated an ability to reduce accidents and increase traffic flow by decreasing congestion and delays at urban intersections.The first AIMs were proposed by Dresner et al. in ,6,7,8,9.Since FCFS presented several serious problems that could lead to risky situations , Huang eOther FCFS improvements were those developed by ,12, throAn alternative to FCFS was suggested by , in whicOther control techniques, in addition to FCFS, use mathematical optimizations to determine the passing priority policy ,16,17,18A control policy different from FCFS was proposed by Carlino et al. in , where tSome works use Reinforcement Learning (RL) to address this approach. For example, the works proposed in ,20 used Another work using Deep Reinforcement Learning (DRL) was presented in , where DAs we have seen in this short review of the state of the art, most of the work focused on AIM is based on communication between VAs and IMs but does not consider the latency required for communication between them. There is a small set of works that have taken it into account ,24,25,26Another interesting work that accounts for Round-Trip communication Delay (RTD) was presented by Andert et al. in . In thisIt is clear that the works on AIM so far have focused on improving vehicular flow as well as reducing lost time, but very few have considered the influence of latency inherent in wireless communication systems. As a result, we believe that there is still a dearth of work addressing the study of latency in AIMs, particularly using advanced approaches such as multi-agent DRL, in which the system can learn autonomously without the need for any control rules and obtain advanced control techniques. By doing so, it could offer higher security and the possibility to learn from the environment under control to perfectly adapt its behavior to the conditions and properties.adv.RAIM [adv.RAIM implements an advanced cooperative AV control system for urban intersections using AI algorithms. Specifically, it uses DRL’s TD3 algorithm along with other algorithms designed to accelerate training, such as PER. adv.RAIM offers an advanced control policy in an ego way, i.e., it processes all AVs recursively, calculating the speed at which each AV should travel during the next control interval as a function of the ego-vehicle’s state and the other “collaborating” vehicles’ states. This process is repeated periodically every timestep for all AVs (250 ms).AIM5LA is based on adv.RAIM . adv.RAIadv.RAIM is included within the collaborative problems and follows the mechanism of centralized training and centralized execution, which allows for the obtaining of the better performance of the experiences performed by the different actors (vehicles) in the environment (intersection). The experiences are centralized in the IM, being the IM in charge of executing the control policy for all the controlled AVs. The experiences that each vehicle sends to the IM are composed of the status of each vehicle . When the IM collects all the experiences of all the AVs to be controlled, it has a complete and detailed view of the whole intersection. On these experiences, the DRL algorithm is applied, in which, based on the different actions that the vehicles can perform , it calculates the optimal speeds to be followed by the AVs during the next time interval to minimize the travel time without causing collisions between the AVs.adv.RAIM incorporates a recurrent neural network, a Long Short-Term Memory (LSTM). This LSTM encodes the representation of the characteristics (state) of the other AVs with which the ego-vehicle collaborates into a fixed-size output variable (256) and captures the long-term spatial and temporal dynamics of the traffic conditions in the network. The output of this LSTM was concatenated with the parameters (state) of the ego-vehicle. The main drawback is that adv.RAIM does not take into account the latency inherent to the communication systems. Communication is necessary for the data exchange (status) between AV and the AIM system in charge of calculating adv.RAIM. Although originally adv.RAIM enables accident-free control, this was because it was tested in a traffic simulator without communication latency.In addition, to solve the problem of independence of the number of AVs in the control algorithm, adv.RAIM to take into account the latency of the 5G communication network and thus improve control in real future scenarios where mobile wireless communication protocols such as 5G will be used. The new proposal, called AIM5LA, includes the following improvements and modifications compared to adv.RAIM:-ego-vehicle to be controlled in the previous interval.Incorporates the previous latency experienced by the -ego-vehicle during the next control interval, based on a Transformer deep neural network and the history of latencies experienced, as well as the number of AVs to be controlled simultaneously.Includes a novel latency prediction module that predicts the latency experienced by the -Considers the latency experienced by other AVs at the intersection using an encoder LSTM network.-Finally, we propose the set of messages, the time intervals between each message, as well as the communication protocol, to implement AIM5LA.Due to the lack of works exploring this problem using DRL, in this work, we proposed to evolve In our humble experience, this is the first latency-aware AIM trained entirely by DRL. When we say it is latency-aware of the communications network, we mean that AIM5LA is able to learn a control policy that can deal with changes in communications latencies and thus internally model the behavior of AVs based on their latency, and therefore adapt the control of these AVs to avoid collisions.Without considering communication latency, a delay in control could cause an AV to receive a command later than desired, leading to undesirable situations, including collisions.Once the above modifications have been included, a representation of the AIM5LA architecture can be seen in ego-vehicle will experience in the next time interval based on the history , as well as a timestamp used to estimate the latency in the communication channel. This timestamp is the internal time of the IM just before sending the message. This message is sent periodically with a sending period such as to allow safe control of the AVs, but without saturating the communication channel. A suitable period is 250 ms, based on the control intervals of other works [adv.RAIM [-er works ,31 and oadv.RAIM  developmprobe message from the IMs, checks whether its geographical position and route match with the IM that should control it, responding to this message with a control request message.The other message timing is adjusted to meet with the 250 ms update period. Each vehicle, after receiving the This periodicity enables sequential and temporally separated control of all AVs without saturating the processing or communication channel, as well as safe and fast control with sufficient anticipation.Request: These messages are sent by AVs to the IM to indicate that they want to be controlled during the next control interval (250 ms). To avoid channel saturation and delays due to overlapping with other AVs that want to send the control request message, AVs wait a random time t to send the control request message. The random time t is used to reduce the probability of overlap of sending messages when multiple AVs attempt to access the 5G URLLC channel resources and thus remove this overlap from the latency calculation. After performing a preliminary set of experiments in the Simu5G simulator [t follow a continuous uniform distribution with a minimum value of 0 ms and a maximum value of 50 ms. This interval minimizes the probability of overlap with other AVs, considering the use case of an intersection; furthermore, it allows a compromise so that all control requests can be processed in real-time. The control request message includes a vehicle identifier and the timestamp resulting from adding the random time t for sending the control request message to the timestamp captured from the IM probe message. In addition, it includes the internal parameters necessary for the cooperative control of the AVs, which include geographical position , speed, acceleration, branch of the intersection , lane in which it travels , route it intends to follow , type of vehicle, physical characteristics , and technical characteristics . With this message, the AIM can estimate the latency existing in the wireless communication channel. When the IM receives the message from the AV, it only has to compare the timestamp included in the message with the internal timestamp, so it calculates the latency existing in the complete IM-AV–IM path. In addition, a history of the computed latencies allows for the assessment of an estimate of the jitter, which is also an interesting parameter. Finally, thanks to the random time t, the time that each vehicle takes to gather internal parameters  is eliminated in the calculation of the communication channel latency.-imulator , it has Action: This message is sent from the IM to each controlled AV and indicates the action to be performed at that moment until the next control interval. This message may include speed, acceleration, steering wheel position, geographical route to follow, speed and acceleration profile, etc. The calculation of this action already takes into account the possible latency of the wireless communication channel as well as the influence of the other AVs at the intersection. In this case, AIM5LA predicts the speed to be followed by the ego-vehicle during the next control interval.-probe message (at time T1), the AVs are given enough time to respond, taking into account the communication latency, as well as the random time t  that each vehicle waits to respond. The time allotted to listen to control requests (control request messages) is 100 ms. This value takes into account the up to 50 ms that an AV may wait to respond to the probe message and the latency that may exist in the system in the extreme case of a saturated scenario [The message exchange diagram can be seen in scenario ,33. In orequest message is received from vehicle request message, and probe message.Consequently, the AIM can calculate the average latency request messages and the internal captured timestamps of these messages. This latency is also fed into the vehicle control decision-making process implemented in this work using AIM5LA, in addition to forecasting the latency behavior. This stage was assigned a maximum time of 75 ms. This time is based on the time required to perform the inference of the deep learning models employed, as well as the remaining time of the self-imposed control period (250–100 ms of the probe + request messages). The actual inference time is expected to be much less than this time due to the use of concurrent computing techniques, pruning, knowledge distillation, and half-precision floating-point operations.From that moment on, the AIM starts processing the requests to obtain the best actions that AVs should perform in the next control interval. As a result, it will have the most up-to-date information from all vehicles, as well as from other data sources such as cameras, people counters, sensors, etc. In addition, the AIM can already estimate the latency of the communication between each of the AVs using the timestamps included in the actions to be performed/maintained during the next interval are sent consecutively to each AV. For this process, we assign a maximum of 75 ms, which is the remaining time of the control interval period . Then, the process is started again, but this time with the time instant T2 .Finally, the In this section, the testbed is developed for AIM5LA training as well as the simulated scenarios.To evaluate the performance of AIM5LA and the proposed message protocol, several scenarios were designed. The first scenario was used to train AIM5LA to find an advanced control policy that takes into account the wireless communication latency. The second scenario aimed to show the performance of AIM5LA in a scenario never seen before by the algorithm during training to demonstrate that AIM5LA can find robust control despite confronting unknown traffic and latency situations. In addition, before carrying out the experiments in these scenarios, the latency predictor module had to be optimized in a scenario using the Simu5G 5G computer simulation tool .AIM5LA derives its control policy from DRL  and makeTo simulate the wireless communication channel and protocol, the 5G simulator Simu5G 1.2.0  was usedFor the simulation of vehicles, their behavior, and urban roads, SUMO 1.8.0  was usedFor the development of AIM5LA, as well as all the deep learning algorithms, Python 3.8.10 was used together with the deep learning framework PyTorch 1.9.0 with CUDA . As for probe message periodically (every 250 ms), and when this message was received by the vehicles, the vehicles responded with a control request message after a random time t that followed a uniform distribution with a minimum of 0 ms and a maximum of 50 ms, as shown in the previous section.First, the latency prediction module was optimized. We called it Experiment #1. We did the optimization by simulating a simple 2-lane, traffic light-controlled 60-s cycle intersection with an increasing number of vehicles. This is because it has been shown in previous works ,33 that probe messages every 250 ms. The scenario had a duration of 300 s, and the first 250 s of the simulation were used as the training dataset and the last 50 s as a testing dataset, obtaining an 83%/17% split of the dataset. The forecaster predicts the latency experienced based on previous latencies, i.e., it considers a previous temporal window  was configured to send dow h in  to forecFinally, the latency forecast module included a neural network based on Transformers, with an output of 1 hidden neuron. The output of this network was concatenated with the number of simulated AVs variable and these variables were used as input to a deep neural network composed of 3 Fully Connected (FC) layers, with 64, 16, and 1 neuron in each layer, respectively, with ReLU as activation functions in the hidden layers. The neuron in the last layer is responsible for providing the latency forecast output during the next control interval. A representation of the architecture of the prediction module can be seen in Once the latency forecast module was optimized, the AIM5LA control algorithm could be optimized. The results of this optimization can be seen in the following section.To optimize the AIM5LA control algorithm, another scenario was developed, namely Experiment #2, consisting of an intersection with an AIM in charge of controlling the vehicles crossing that intersection. The intersection had four 200-m branches , 3 lanes per direction, left turns, straight ahead, and right turns were allowed. AVs were controlled when within 100 m of the center of the intersection. A representation of this scenario can be seen in To obtain a wide variety of situations that challenge the control algorithm, the simulated flow pattern was set as shown in -−100 when there was an accident;-+100 when a vehicle crossed the intersection without an accident;-−control interval (−0.25) at each simulation interval to encourage optimization of time loss and crossing as quickly as possible.The metrics, optimized by the DRL algorithm, were the number of collisions and time loss of vehicles due to intersection congestion, with the reward function followed by the DRL algorithm being as follows:These reward signals are determined in the original paper . The metA final scenario was composed of a Manhattan network of 100 intersections (10 × 10) to show the performance of the AIM5LA algorithm, namely Experiment #3. At each intersection, there was an AIM in charge of controlling the vehicles crossing it. The intersections were separated by 250 m, with a similar configuration to the training scenario . In addition, to illustrate singular situations, a different flow behavior was simulated, shown in 2, PMx), and fuel and electric consumption. Although all the metrics showed are not directly optimized, they are indirectly optimized through the overall optimization process.The metrics analyzed in the test scenario were diverse because SUMO provides a complete set of metrics after each simulation. These metrics were time loss due to congestion at intersections, number of collisions, average waiting time, various pollutant gas metrics  and AIM5LA_v0.1 + the latency forecaster module . The use of the preliminary versions of AIM5LA (AIM5LA_v0.1 and AIM5LA_v0.2) serves as an ablation study, allowing us to show the importance of each module, as well as to isolate their contribution. The results obtained with traffic-light based control algorithms have been incorporated as well; particularly, a fixed time control (FX) system with different cycle lengths  and an intelligent advanced traffic light control technique (iREDVD) [To compare the performance of AIM5LA with other algorithms, we also included the performance evaluation of adv.RAIM , the AIMadv.RAIM , and twoIn this section, we show and discuss the results.After performing the simulations, the average latency, as well as its standard deviation as a function of the number of simulated vehicles, can be seen in The temporal behavior of the latency for a random vehicle in each of the simulated scenarios can be seen in Once we had simulated the behavior of the AVs in OMNeT++ using the Simu5G library and obtained the experienced latency, we had a dataset that could be used to train the latency prediction module. For the division of the dataset, the first 250 s of latencies were used as the training dataset, and the remaining 50 s were left as the test and validation dataset. This division of the dataset can be seen graphically in h in The results of the training and testing can be seen in h) was about 10 samples, since it makes the least error with the smallest window size. Finally, when we considered 10 previous samples for latency prediction at the next time instant, as well as the number of simultaneous vehicles, the mean value and standard deviation of the RMSE results were 0.4551 ± 0.0264 in the training set and 0.3702 ± 0.0301 in the test dataset.From these results, the optimal size of the historical latency window  of simulation and training for the three runs, using an Intel 8-core/16-thread processor (i7-11700k) and an Nvidia RTX 3080 GPU.The training results show the great performance offered by AIM5LA, being able to completely reduce collisions from about simulation 10Finally, after the training process, AIM5LA was compared with other AIM and traffic-light based protocols in the test scenario described above. The results are included in adv.RAIM [AIM5LA presents an excellent performance, being the only AIM protocol able to reduce accidents in the test scenario. Looking at other metrics such as time loss, waiting time, pollution, or fuel consumption metrics, AIM5LA can achieve a performance similar to other AIM techniques such as the one proposed by Andert et al.  or adv.Radv.RAIM . Howeverego-vehicle), we see that there are some collisions that AIM5LA_v0.1 is not able to eliminate due to the instability of the channel in the latency behavior, as well as due to the influence of other AVs. Last, when compared to AIM5LA_v0.2 , the result is significantly improved. However, there is still a small number of collisions that are completely eliminated when using the final version of AIM5LA.On the other hand, comparing AIM5LA with the v0.1 version of AIM5LA  algorithms, or a reduction of more than 99.52% in waiting time. When comparing AIM5LA with other advanced traffic light control techniques . In particular, they are complex and chaotic environments that require advanced control to ensure maximum safety. One of the solutions proposed by the scientific community to control AVs at intersections is Autonomous Intersection Management (AIM). AIM is based on communication between AVs and a control entity located at each intersection to obtain a joint control policy that improves the intersection flow. However, the vast majority of AIMs ignore the latency that may exist in the communication channel, which poses a great safety vulnerability and a high risk of accidents.The main contribution of this work is the development of a latency-aware AIM for 5G communication networks integrally trained by Multi-Agent Deep Reinforcement Learning (MADRL). Our proposal uses a MADRL algorithm with centralized training and centralized execution and a network latency forecasting module to obtain an advanced control policy to ensure control security and reduce traffic congestion. In addition, our proposal uses a novel latency predictor module that employs a Transformer-based deep neural network. This is the first latency-aware AIM fully trained by MADRL. When we say latency-aware, we mean that our proposal adapts the control of the AVs to the inherent latency of the 5G network, thus providing traffic security and fluidity. The system was named AIM5LA, and beyond considering the latency history experienced, AIM5LA predicts future latency behavior to provide better security and improve traffic flow through the latency predictor module. AIM5LA was compared with other AIMs  as well First, the latency prediction module was able to obtain surprising results, achieving an RMSE of less than 0.4. This allowed it to predict with high accuracy the latency that an AV would suffer during the next control interval. When comparing AIM5LA with traditional traffic-light based control techniques, AIM5LA is able to reduce the time loss by 92%, as well as the waiting time by more than 99%. Furthermore, compared to advanced adaptive traffic light control techniques such as iREDVD, AIM5LA was able to reduce time loss by 84.51% and achieve a significant reduction in other metrics such as time loss (84.51%), waiting time (99.25%), fuel consumption (35.67%), or pollutant gas emissions (48.50%). Moreover, observing the results obtained with AIM5LA during the ablation study (v0.1 and v0.2), it is possible to observe the contributions of the different modules developed, as well as the importance of considering them in different metrics such as travel time, number of collisions, etc. More specifically, only the full version of AIM5LA can eliminate crashes in the test scenario. The most important lessons learned during this work included the importance of the latency prediction module to eliminate collisions, as well as the importance of using centralized training and end-to-end multi-agent deep reinforcement learning algorithms, with excellent action space exploration, to obtain high efficiency in future AIM systems.In future work, the forthcoming 6G architecture will be considered, as well as the inclusion of unmanned aerial nodes to reduce communication latency and analyze performance in a real 5G system.


The United States (U.S.) Department of Agriculture (USDA)-administered Supplemental Nutrition Assistance Program (SNAP) made substantial changes in response to the coronavirus disease 2019 (COVID-19) pandemic. These changes highlight the need to identify the digital literacy skills and capacities of SNAP adults to purchase healthy groceries online. We conducted a scoping review of four electronic databases, Google and Google Scholar to identify studies that measured food and nutrition literacy outcomes for U.S. adults. We applied a multi-dimensional digital food and nutrition literacy (MDFNL) model to assess six literacy levels and components. Of 18 studies published from 2006–2021, all measured functional and interactive literacy but no study measured communicative, critical, translational, or digital literacy. Six studies examined SNAP or SNAP-Education outcomes. Adults with higher food or nutrition literacy scores had better cognitive, behavioral, food security and health outcomes. We suggest how these findings may inform research, policies, and actions to strengthen the multi-dimensional literacy skills of SNAP participants and SNAP-eligible adults to support healthy purchases in the online food retail ecosystem. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that caused the coronavirus disease 2019 (COVID-19) spread throughout the United States (U.S.) and globally in late 2019 through 2021. By June 2021, COVID-19 had infected over 33 million Americans and caused more than 599,000 deaths . By DeceCOVID-19 disrupted the U.S. food supply, distribution, and services systems and produced major changes in the federal government’s safety-net programs . The SupPrior to the COVID-19 pandemic, U.S. household food insecurity rates were about 10.5 percent in 2019, representing 13.7 million households and 35 million Americans. These rates were higher for households with children, with 13.6 percent of households facing food insecurity and millions of children who experienced disrupted eating and hunger . These pCOVID-19 shifted the way that Americans access, purchase, prepare and eat food. In response to the pandemic and the resulting restrictions and safety precautions, Americans made fewer in-person grocery shopping trips; used online cashless e-commerce platforms to order food and groceries for delivery or pick up; prepared and ate more meals at home with their families; stockpiled a higher proportion of shelf-stable, frozen, and highly processed food products or prepared meals; and were exposed to more direct-to-consumer branded product advertising through online digital marketing platforms ,15,16,17The Families First Coronavirus Response Act of 2020 provided the USDA Secretary with the authority to approve state agency waivers to change the emergency SNAP eligibility standards and provide pandemic electronic benefits transfer (P-EBT) benefits to eligible Americans . In respBefore 2020, online grocery shopping represented less than three percent of SNAP users’ spending . SNAP reAffordable access to broadband internet services is a social determinant of health , yet an The digital divide disproportionately affects low-income and racially or ethnically diverse older adults, non-native English-speakers, the disabled, and senior citizens who do not have access to high-speed 4G or 5G broadband internet services or lack the skills to use digital technology. Therefore, daily activities, such as scheduling telemedicine appointments with healthcare providers, buying groceries, or paying bills online, are affected ,34. The The United Nations Nutrition defines digital literacy as “the ability and skills to find, evaluate, create and communicate information effectively using digital technologies and platforms” . The groEvidence shows that an increase in SNAP benefits may improve the food security status of low-income households, but not necessarily improve overall diet quality . ResearcSNAP-Education (SNAP-Ed) is a federal program that supports SNAP participants by providing nutrition education, including food resource management and access to affordable and nutritious foods and beverages . SNAP-EdThe aim of this study is to apply a newly developed Multi-Dimensional Digital Food and Nutrition Literacy (MDFNL) model  Figure  to examiThis study was guided by two research questions (RQ):RQ1: What does the available evidence show about the literacy capacities and skills of American adults, especially low-income SNAP adults, to make healthy and affordable purchases within the online food retail ecosystem?RQ2: How can the MDFNL model be used to assess the available evidence on U.S. adults’ literacy capacities and skills for online purchases to inform future policy and research?The study used a systematic scoping review process, guided by a restricted review framework , to compThe first author, K.C.S., worked with university librarians to develop the search strategy to compile data to inform RQ1. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P)  and the The search identified primary evidence sources that assessed nutrition or food literacy characteristics and cognitive, behavioral, food security, and/or health outcomes relevant to understanding the capacities and skills of SNAP adults operating in the online digital food retail ecosystem. K.C.S. conducted the electronic searches, screened, and identified relevant full-text articles for consideration. Two co-authors, K.C.S. and P.B.H., independently reviewed the full-text articles for alignment with the PICOTS criteria and discussed or resolved any discrepancies related to the interpretation of evidence sources. P.B.H. conducted the data extraction and created an evidence table to summarize the lead author and year published; the study objective; the population and location; the study design and data collection period; the cognitive, behavioral, food security, and/or health outcomes; and the major study findings. The lead author (K.C.S.) developed a separate evidence table to summarize the self-reported type of literacy assessed; the literacy tool used; the literacy capacities and skills measured; and the level of literacy measured based on the MDFNL model .n = 18) measured functional and interactive literacy. However, no studies assessed more advanced literacy skills as reflected in the communicative, critical, and translational levels of the MDFNL model  provides many resources for educators and childcare providers to support health literacy in children, adolescents, and young adults . HoweverWe did not identify any studies that measured digital access as it relates to food and nutrition literacy. However, access to the internet and to digital technology are important precursors to individuals’ abilities to develop digital technology skills. The U.S. government has prioritized the expansion of high-speed internet and broadband access for all Americans through the 2021 Build Back Better initiative and a bipartisan infrastructure package. The FCC is also working to subsidize and expand broadband accessibility and affordability for low-income and rural households through the Emergency Broadband Benefit Program and Rural Digital Opportunity Fund ,85. ThesThe growth of digital platform use for food shopping highlights a need to provide education, skills, and legislation to support Americans’ safety, privacy, and security when navigating the digital retail ecosystem. As the Center for Digital Democracy outlined in a 2020 report, online food retailers are able to access and track consumers’ purchase behaviors, location, and personal information and share this information with food manufacturers, advertisers or other third parties, often without consumers’ knowledge ,88. ThisOlzenak et al., 2020  found thAs noted in a 2021 research report , followiWhile six of the identified studies used literacy tools to assess the skills and capacities of SNAP adults, no literacy tools were developed specifically for low-income SNAP adults. Many SNAP adults face unique needs and challenges, such as a lack of social support or lower educational attainment, that may influence their capacity to respond to the standard numeracy- and reading-focused questions used in existing literacy tools. The USDA should support the development, testing, and validation of a tool to assess the multi-dimensional digital food and nutrition literacy status of SNAP adults. The USDA and partners could use the MDFNL model as a foundation to develop this literacy tool. Academic researchers, professional societies, private foundations, and civil society organizations would be key stakeholders to support this process.The U.S. Congress could authorize and appropriate adequate funding in the 2023 U.S. Farm Bill legislation to support the inclusion of digital food, nutrition, financial, and health literacy skills into SNAP and SNAP-Ed messaging to support policies, systems, and environmental interventions that promote healthy eating patterns . The USDAs the USDA expands its use of digital platforms and technology for SNAP and SNAP-Ed, greater attention is needed to address SNAP adults’ access to broadband and digital technologies and the safety measures in place to support them in navigating the digital retail ecosystem. In addition to supporting research to better understand SNAP adults’ barriers to online grocery shopping, the USDA should also implement the Center for Digital Democracy’s recommendations to protect SNAP adults while navigating the online retail ecosystem . These rA strength of this study was the extensive interdisciplinary literature searched to identify the 18 U.S. food and nutrition literacy studies reviewed, and the development of policy-relevant recommendations for the current U.S. political context. A limitation is that, due to time constraints, only one researcher screened articles for inclusion and extracted data for the 18 included studies, which could have introduced bias in the evidence analysis and synthesis. The MDFNL model  should bLimited literature exists that assesses the nutrition and/or food literacy status of Americans, particularly SNAP adults, and no literature was identified that evaluates Americans’ digital literacy skills and capacities when functioning in an online food retail environment. Existing studies that examine nutrition and/or food literacy only assessed low levels of literacy and did not take into account higher level digital food and nutrition literacy skills needed to function in a e-commerce world. This study identified a need to develop and test more robust literacy assessment instruments that include digital literacy principles. This study also identified a need for greater research, policies, and actions to address the research gaps for Americans’ digital food and nutrition literacy skills and to help SNAP adults navigate the purchase of healthy products online. With online grocery shopping expected to expand given food retailers’ increasing reliance on digital technology, opportunities exist for U.S. government agencies, academia, foundations, and civil society to support research and policies to strengthen MDFNL skills and infrastructure to support a healthy online food retail ecosystem for Americans, especially for SNAP adults.


The North American opioid crisis is marked by high opioid-related mortality and morbidity, including opioid use-associated infections (OUAIs). Users of pharmaceutical and non-pharmaceutical opioids are at an increased risk of acquiring hepatitis C (HCV), human immunodeficiency virus (HIV), and other infections. No high-level evidence, however, has been synthesized regarding effectiveness of interventions to prevent OUAIs in legal, and illegal/mixed opioid users. The aim of the study is to synthesize available systematic review (SR)–level evidence on the scope and effectiveness of interventions to prevent OUAIs among opioid users.A SR of SRs approach was applied. We searched PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Epistemonikos and Google Scholar from inception to September 2020. Data selection and extraction were performed independently by three researchers. Risk of bias and quality of evidence were assessed using the AMSTAR2 tool. Results were narratively synthesized. Strength of evidence for each category was reported.Eleven of twelve identified SRs included interventions to prevent HCV/HIV transmission in persons who inject drugs (PWID), including opioids. One SR evaluated interventions to prevent recurrent infectious endocarditis. There was sufficient and tentative SR of SRs-level evidence for the effectiveness of opioid substitution therapy (OST) in preventing HIV and HCV, respectively. We found tentative evidence to support effectiveness of needle/syringe exchange programs (NSP) in HIV prevention, and sufficient evidence to support effectiveness of the combined OST and NSP in HCV prevention. There was insufficient SR-level evidence to support or discount effectiveness of other interventions to prevent OUAIs. No SR focused on non-PWID populations.SR-level evidence supports the use of OST, NSP, and combined interventions for the reduction of HCV and HIV transmission in PWID. More research on prevention of other OUAIs and on prevention of OUAIs in non-PWID populations is urgently needed.https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=195929, identifier: #195929.Registered in PROSPERO on July 30, 2020.  The North American opioid crisis is a major public health emergency –3. Half Although opioid-induced morbidity has not gained as much attention as opioid-associated mortality, it also constitutes serious health and economic burden. In addition to being acquired via sharing contaminated equipment by illegal users and by risky behavior like unprotected sex, it is theorized that OUAIs entry could be facilitating secondary immunosuppressive properties of many opioids. Users of illegally obtained pharmaceutical   or non-pMany OUAIs, including HCV and HIV, are preventable . In the To identify potential scope and types of interventions aimed to prevent problems associated with the opioid crisis, an initial search for an overarching research project  was performed in 2019. Among others, this search produced 18 systematic reviews (SRs)  related To account for the above, this systematic review of SRs (SR of SRs) was designed to capture a broader scope of preventive interventions with evaluated effectiveness by including all types of opioids users , pharmaceutical and non-pharmaceutical opioids, and all routes of use. Our review question was “What is the SR-level evidence on the scope and effectiveness of interventions to prevent common infections in people who use opioids?”The specific objectives were: (1) to describe SR-level evidence for the scope of interventions with evaluated effectiveness in prevention of OUAIs; (2) to synthesize the SR-level evidence on the effectiveness of interventions in preventing OUAIs; and (3) to identify knowledge gaps in this area. With a growing literature on a variety of infections and immunosuppression associated with the use of opioids, of special interest for the authors was to identify the evidence on the effectiveness of interventions to prevent OUAI in the population other than PWID and on infections other than HCV and HIV. In light of the worsening opioid crisis and overstretched healthcare resources, synthesizing the highest level (SR-level) of evidence is a timely and necessary effort to inform knowledge users and policy/decision makers about the effectiveness of OUAIs preventive strategies and existing knowledge gaps in this area.To address the review question, we synthesized SR of SRs-level evidence on the scope and effectiveness of interventions to prevent OUAIs. The detailed description of Methods and our PICO question, including all elements, are provided in the For the purposes of this SR of SRs, we roughly categorized opioid use into legal and illegal/mixed opioid consumption. Opioid use was defined as any opioid use via any route of administration. This includes opioid co-use with other substances. Legal use was defined as the use of therapeutically prescribed pharmaceutical opioids  by the pWe applied an SR of SRs approach , a subtyThe protocol was registered in PROSPERO on July 30, 2020 (#195929).We conducted a systematic search of PubMed, Ovid Embase, Ovid PsycINFO, Cochrane Database of Systematic Reviews, Epistemonikos and Google Scholar databases from inception to February 2020, with the search updated in September 2020. The search strategy was based on the following 4 concepts joined by the Boolean operator “AND”: (1) opioids ; (2) infections ; (3) preventive interventions  and (4) systematic reviews with or without meta-analysis. The complete search strategy is presented in Included studies were SRs synthesizing studies of interventions to reduce or prevent infection transmission/acquisition among users of pharmaceutical or non-pharmaceutical opioids by any route of use, and reporting on the effectiveness of the interventions, with or without meta-analysis. A publication was considered an SR if it was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist and met the following criteria: (1) described methods, comprising a systematic search strategy and criteria for inclusion/exclusion; (2) used a comprehensive search in all relevant databases and an exhaustive search strategy; (3) performed a formal quality assessment of included studies applying a validated tool . Only reviews with retrievable full text articles in English or French were included. SRs that synthesized information on the studies not relevant to the North American context  were excluded. Conference abstracts were not eligible for inclusion. Only studies where outcome of the intervention/s were clearly identified and the effectiveness of interventions was evaluated were included. SR that synthesized information of all study types  either with a comparator group (opioid users not participating in an intervention/program/not affected by a policy/approach) or time/population prior to implementation of policy (for population-level studies) were included.The outcome of Objective 1 was the scope of interventions for prevention of infections in opioid users. The outcome of Objective 2 was effectiveness of interventions to prevent infections in opioid users, potentially appropriate for the North American context. Measures of effectiveness of the intervention/program/policy were effect measures of an association between infection/disease incidence  and participation in the intervention, estimated by either odds ratio, risk ratio, or hazard ratio in participants or groups. For SRs with meta-analysis, pooled effect measures were reviewed. For SRs without meta-analysis, effect measures reported by original studies were extracted. The outcome of Objective 3 was the identification of knowledge gaps in the studied area.https://libraryguides.mcgill.ca/rayyan#s-lg-box-13326907) and an Excel spreadsheet were used to record decisions and reasons for exclusion. The “Endnote” bibliographic software (Endnote X8.1) was used for duplicates removal and storage.First, titles and abstracts of all records identified through the systematic search were screened by three members of the research team  independently. Any potentially relevant study identified by either reviewer was carried forward. Subsequently, full texts of potentially eligible publications were reviewed independently by SP and IK, with disagreements resolved by consensus. The publications remaining after this full text review were included. The RAYYAN platform (available at McGill: Two researchers (SP and IK) independently extracted the data using a standardized, pilot-tested data collection form, according to Cochrane recommendations for overviews of SRs . In caseRisk of bias/methodological quality of included SRs was assessed using the AMSTAR 2 tool . The criFigure 3 and presented as a Overlap of the primary studies was mapped by providing a citation matrix  Table 2Table 2. A total of 1,243 potentially relevant publications were identified via the systematic search . After rCharacteristics of included SRs are shown in Overall, we identified 8 different types of preventive interventions . Eleven A scope of interventions (our first objective) is presented in The results of effectiveness of all interventions are summarized in NSP. Most included SRs on the use of NSP focused on the prevention of HCV: three SRs studied HCV prevention only and two SRs studied HCV and HIV prevention. One SR  to prevent HIV and HCV, respectively. Tentative evidence to support effectiveness of needle/syringe exchange programs (NSP) in HIV, but not HCV, prevention, was found. There was sufficient evidence to support the effectiveness of combined OST and NSP interventions in HCV prevention. The SR-level evidence to support the effectiveness of other interventions to prevent OUAIs was insufficient.Our results are in line with findings of previously published overviews of reviews. More specifically, McArthur et al.  found suThe third objective of our SR of SRs resulted in the identification of several important knowledge gaps existing in the systematic review literature on the effectiveness of interventions to prevent OUAIs. One of the important omissions in the reviewed literature was not specifying the type of a drug used by the participants, except for the SRs devoted to OST. Furthermore, the co-use of drugs vs. exclusive opioid use was seldom reported. We postulate that this discrepancy could partly explain the mixed results in different primary studies since use of a specific substance vs. co-use of different substances might modify effects on ensuing users' behaviors and its consequences. For example, it has been previously reported  that co-Furthermore, we did not find any SR that evaluated interventions to prevent infections in patients using pharmaceutical opioids prescribed by a health professional. These infections, however, despite the legal origin of opioids, can contribute to an increase in opioid-related morbidity and mortality. Adaptive immunity and, therefore, risk to acquire an infection, can depend on the type of opioid . For exaAnother identified knowledge gap is a lack of SR-level evidence on OUAIs other than HIV and HCV. Most bacterial infections associated with opioid use can result in substantial morbidity. We did find one SR evaluating the effectiveness of interventions to prevent infectious endocarditis . HoweverOur SR of SRs demonstrates that existing evidence on the effectiveness of preventive interventions against HIV and HCV infections is much more abundant than the information on prevention of other OUAIs. This finding suggests that attention should now be re-focused to the less developed knowledge areas. For example, skin and vein care is an essential part of NSP, targeting both viral and bacterial infection complications. There is, however, a lack of studies evaluating effectiveness of NSP, or other interventions, in prevention of skin and vein infections to inform best practices. In addition, the literature suggests that the prevention of sepsis plays an important role in the care of all types of opioid users. In a US cohort based in 373 hospitals, almost half of the mortality outcomes were associated with sepsis diagnosis . The proGiven the ubiquitous legal and illegal use of opioids in North America, including long-term use in high immunosuppressive doses, the knowledge on the effective prevention of OUAIs is of paramount importance to all healthcare professionals encountering these vulnerable patients as well as to the policy and decision makers.To our knowledge, this is the first broad scope SR of SRs that synthesized SR-level evidence on the effectiveness of interventions to prevent common infections in people who use pharmaceutical and non-pharmaceutical opioids, legally and/or illegally, via any route of administration. It was conducted in response to the North American opioid crisis and in an effort to help curb opioid-related morbidity and mortality. We have followed a pre-specified, registered protocol. The quality assessment of included SRs was conducted, and the quality of synthesized evidence was graded using previously used validated tools. The main strength of the present work is its SR of SRs design. This methodology allows synthesizing the highest level of evidence in a user-friendly format to help knowledge users and policy makers to take informed decisions.There are some potential limitations. First, this study is limited to the evidence from published SRs only. Thus, we exclude the evidence from other types of literature. Moreover, most eligible SRs were focused on population-based interventions, therefore, the conclusions made by the authors of these SRs should be considered with respect to the limitations of observational studies. Further, our definition of SR complies with the PRISMA checklist. Therefore, some studies published as SRs that did not meet the PRISMA checklist selection criteria were excluded. This approach may have restricted the scope of interventions. Second, there could have been a language bias for publications in languages other than English and French. Our intention, however, was to synthesize the evidence on interventions most relevant to the North American context. Finally, we could not use the GRADE system to evaluate the level of certainty of the evidence since it has not yet been developed for SR of SRs. We, however, used a method that has been previously applied to the published overview of reviews.Our SR of SRs demonstrates that current focus of existing SRs evaluating effectiveness of interventions to prevent opioid use-associated infections centers almost exclusively on interventions to prevent HCV and HIV transmission and acquisition in users of non-pharmaceutical opioids, specifically in PWID. Of all interventions, the SR of SRs-level of evidence was the strongest for the effectiveness of OST in prevention of HIV (sufficient) and HCV (tentative), for the effectiveness of NSP to prevent HIV (tentative), and for the effectiveness of the combination of both these interventions to prevent HCV (sufficient). The evidence on prevention of recurrent infectious endocarditis in persons who inject opioids is scarce and does not allow for an SR-level conclusion. We identified several important knowledge gaps, such as a scarcity of SR-level evidence on the interventions to prevent infections other than HCV and HIV, as well as intervention targeting users of pharmaceutical opioids in legal and mixed opioid users. Systematic implementation of interventions with known effectiveness will assist in curbing opioid-related morbidity and mortality. Knowledge gaps identified in our study should be addressed by researchers and policy makers.The original contributions presented in the study are included in the article/SP: conceptualization, methodology, formal analysis, data curation, visualization, writing—original draft, and writing—review and editing. ME: conceptualization, supervision, and writing—review and editing. KF, AH-L, MM, and SW: writing—review and editing. GG: methodology and writing—review and editing. EP: conceptualization, data curation, and writing—review and editing. IK: conceptualization, methodology, formal analysis, supervision, data curation, and writing—review and editing. All authors contributed to the article and approved the submitted version.This study was funded by the Canadian Institutes of Health Research (#EOC-162067). ME was the Principal Investigator on this grant. IK was supported by la Lettre d'entente no 250 . KF was supported by a Senior Research Scholar award from the Fonds de recherche du Québec – Santé and a William Dawson Scholar award from McGill University.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.


Pelvic floor dysfunction (PFD) is a common problem in both men and women. Despite the high prevalence and negative effects on quality of life, there is still a lack of research in this area which translates into clinical practice and education.My study discusses how gaps and controversies in current research and evidence on PFD might be addressed by positioning PFD within a contemporary biopsychosocial model of care (BPSM).Various databases were searched for relevant studies published between 2010 and 2020 to support hypotheses and statements.My study focuses on the available evidence of PFD in both men and women as related to the themes and sub-themes of the BPSM, and how this available evidence might translate into education and clinical practice. It highlights areas of research, education and clinical practice that need to be explored and how the different components of healthcare may influence one another.Biomedical aspects regarding pelvic health are mostly investigated and taught, whilst psychological, cognitive, behavioural, social and occupational factors, individualised care, communication and therapeutic alliances are still under-investigated and not integrated or translated at a sufficient level into research, education and clinical practice.Incorporating the integration of all factors of the BPSM into research is important for effective knowledge translation and enhancement of a de-compartmentalised approach to management. The interaction between the different components of the BPSM should be investigated especially in a South African population. Pelvic floor dysfunction (PFD) is a common problem experienced in both men and women. It includes problems such as urinary and faecal incontinence, pelvic pain, constipation, sexual dysfunction and pelvic organ prolapse – and the disorders often coexist Bo . Most stDespite the high prevalence of PFD, there is still a lack of research in this area and a lack of evidence regarding the most optimal management of many of these conditions. Healthcare and research, including the management of pelvic dysfunction, were originally based on a biomedical approach which focused only on biological factors, such as weak pelvic floor muscles (PFMs) in the case of PFD. Over the past decades, an alternative conceptual framework, namely, the biopsychosocial model (BPSM) was developed to help clinicians understand the interrelationship between biological, psychological and social aspects when approaching and addressing impairments in patients holistically. However, research, education and training and healthcare structures still sometimes reflect compartmentalised approaches when conceptualising the BPSM  which describes PFD in terms of impairment , disability and restriction of participation (relating to the master themes and sub-themes of the BPSM). Impairments refer to the abnormality or loss of physiological, psychological or anatomical structures or function at the level of the organ WHO . In the Urinary incontinence in women is probably the most researched area with clear evidence on the efficacy of pelvic floor muscles training (PFMT)  of PFD. This phenomenon might partially be explained by the literature emphasising that movement impairment should provide the basis for diagnosis and treatment of dysfunction  in patients with PFD and how these are integrated into the dysfunction. Aspects such as feelings and emotions are mainly covered in quality-of-life assessments; whilst other aspects including perceptions, illness beliefs, general beliefs, self-efficacy, expectations, catastrophising, coping strategies, fear avoidance, readiness, motivation, attitude and patient engagement are still under-investigated whilst looking at the focus of primary outcomes in the majority of studies. However, there are emerging studies for investigating these factors, as indicated in the following paragraphs.Brennand et al.  conducteA systematic review by Imamura et al.  includedSocial and occupational aspects have rarely been investigated in patients with PFD. This is concerning as the main outcome of the management of the patient should be the fulfilment of his or her normal role in society according to the ICF WHO . The onlEvidence is emerging regarding PFMT and PFM function as related to sexual dysfunction , as they are seen as confounding factors that would compromise the validity of the results. The question should, however, be asked to what extent does this approach compromise the validity and generalisability of research findings and the investigation of the holistic treatment approach, where the overlap of BPSM themes and removing of boundaries amongst themes are crucial for the integration of concepts , permitting optimal quality of life through its multifunctional role and where the individual possesses or has access to knowledge, which empowers the ability to prevent or manage dysfunction. (p. 999)Indicated by the prior literature discussion of the BPSM concepts and supported by the above concept analysis, clinicians, educators and researchers should incorporate this comprehensive definition of pelvic floor health in their practice and guidelines. Although the biomedical aspect is an important concept to understand as it underpins the impairments related to the neuromusculoskeletal system in patients with PFD, attention should be given to the interrelationship with other factors of the BPSM to comprehend and research the holistic approach as is encouraged and taught in theory. Although some studies include data on social and psychological themes, these data are not used to compile patient-centred treatment protocols for studies or when treating patients. As indicated, most studies include quality-of-life assessments as a subjective measure to determine symptomatic cure, psychological and social aspects but do not determine the relationship or interaction with other factors of the BPSM and how to incorporate all factors into the management of the patient.In conclusion, linking clinical practice, research, education and knowledge translation, as well as the very complex interactions there can be amongst aspects of the BPSM other than the biomedical, can be explained by the following example on the management approach to PFD. Correct training of a patient requires cognitive skills and understanding from the patient and an effective exercise prescription from the therapist. The patient, therefore, can be seen as an adult learner in this process, which in turn requires additional skills and understanding from the therapist regarding adult learning to deliver the information effectively. One of the guiding principles for effective learning to take place is to consider the patient’s life stages and life events. The learning environment of the patient should reflect the physical, affective-social and intellectual dimensions needed to create an optimal learning climate  and sexual dysfunction. Psychological, cognitive, behavioural, social and occupational factors, individualised care, communication and therapeutic alliances are still under-investigated from a physiotherapeutic perspective. The research related to PFD in men is also still lacking when compared with the evidence available on PFD in women. Incorporating the integration of all factors of the BPSM (themes and sub-themes) into research is important for effective knowledge translation and enhancement of a de-compartmentalised approach into training and clinical practice. Future studies should, therefore, focus on research topics other than biomedical ones or incorporate outcome measures in efficacy studies as related to all aspects of the BPSM. It is also important that the interaction between the different aspects of the BPSM as related to PFD be determined in the future studies.The recommendations and postulations in this study should further be investigated by means of a systematic review to come to a definite conclusion on this topic.


In response to the World Health Organization’s recommendation, policy makers have been adopting evidence-based healthcare approach to promote the development of traditional, complementary and integrative medicine (TCIM) into Hong Kong’s health system. Disseminating synopses of clinical evidence from systematic reviews or randomized trials is regarded as a potentially effective strategy to promote evidence uptake. The study aimed to identify barriers and facilitators to implementing this strategy among Hong Kong Chinese medicine practitioners (CMPs).Twenty-five CMPs aged under 45 years and trained in Hong Kong after reunification with China in 1997 were interviewed individually. Four clinical evidence synopses of randomized trials and systematic reviews on Chinese medicine interventions were presented, and CMPs were asked to comment on their applicability in routine practice. The Consolidated Framework for Implementation Research (CFIR) was applied to guide interview and analysis.The barriers included: i) CMPs’ perceived difficulties in applying complex evidence in decision-making and ii) inadequate training and limited consultation time. The facilitators were i) availability of publicly accessible and user-friendly synopses, ii) formation of community of evidence-based practice among CMPs with input from key opinion leaders, iii) opportunity for interprofessional collaborations with conventional healthcare providers, and iv) patients’ demand for evidence-based clinical advice. Besides, i) CMPs’ knowledge and beliefs in evidence-based healthcare approach, ii) presentations of evidence-based information in the synopses, and iii) clinical decision making as influenced by quality of evidence reported acted as both barriers and facilitators.This CFIR-based qualitative study investigated how the World Health Organization recommendation of promoting evidence use in routine practice was perceived by CMPs trained in Hong Kong after reunification with China in 1997. Key barriers and facilitators to applying evidence were identified. Such results will inform tailoring of implementation strategies for promoting evidence uptake, in the context of a well-developed health system dominated by conventional medicine.The online version contains supplementary material available at 10.1186/s12906-021-03372-5. The World Health Organization (WHO) Traditional Medicine Strategy 2014–2023 advocates the integration of traditional, complementary and integrative medicine (TCIM) into national health systems among member states through the promotion of its evidence-based use . To promThe EBHC approach regards systematic reviews (SRs) and randomized controlled trials (RCTs) as the best study designs to generate or summarize evidence on treatment effectiveness of CM . In the To address the aforementioned barriers, the use of synopses of SRs and RCTs may also be considered. Synopses are structured abstracts of pre-appraised studies that support clinical actions without the need for the clinicians to access or digest the full article . They caWhile the WHO Traditional Medicine Strategy 2014–2023 is advocating TCIM development in an evidence-based manner, little is known about the faciliators and barriers to clinical evidence application in TCIM practice. The Hong Kong case of CM development provides an opportunity to investigate how this strategic recommendation is implemented in a well-developed health system. In this qualitative study, we investigated Hong Kong CMPs’ perceptions of applying results from evidence-based synopses in their routine practice from an implementation science perspective. The objective was to identify key barriers and facilitators to using results from such synopses in CMPs’ routine practice. Implications from these findings may inform future development of potential implementation strategies for enhancing evidence uptake among CMPs.In-depth individual interviews were conducted during two periods with 25 CMPs aged below 45 years. All participants were trained in Chinese medicine in Hong Kong after reunification with China in 1997. The first phase of interviews was carried out among 15 CMPs in April 2017. Upon completion of analysis, we noticed that further interviews should be conducted to advance our understanding on CMPs’ perceptions towards the application of results from evidence-based synopses in their routine practice more comprehensively. Hence, second phase of interviews was performed among 10 CMPs in April 2020. Results generated from additional data confirmed that saturation was reached with no new perspectives being discovered when the sample size reached 25. A qualitative approach was chosen because little is known about facilitators and barriers to using evidence in routine CM outpatient practice in Hong Kong. Interviews were considered as the most relevant method for collecting exploratory information and gaining a deeper understanding of this issue.The discussion focused on four critically appraised evidence-based synopses on CM interventions, including the most commonly applied modalities of Chinese herbal medicine and acupuncture  and one research personnel (JVHT) either at the CMP’s clinic or at the University. VCHC is a Hong Kong registered CMP with more than 15 years of experience in clinical epidemiology, EBHC teaching and research. CHLW is a public health researcher with significant experiences in conducting qualitative interviews and analysis, while JVHT is a registered CMP with qualitative research experiences. Written informed consent was obtained from participants and all of them agreed to participate in the study. The study was approved by the Survey and Behavioral Research Ethics Committee, The Chinese University of Hong Kong, Hong Kong [reference no.: 101–16].A semi-structured interview guide  iteratively as the interviews proceeded. First, two investigators (CHLW and JVHT) were responsible for coding the transcribed interviews based on CFIR using NVivo software . ImportaAnalysis of the interview data yielded findings that could be mapped onto nine constructs in four CFIR domains: characteristics of individuals (one construct). intervention characteristics (three constructs), inner setting (three constructs), outer setting (two constructs). These constructs acted as barriers or/ and facilitators to using results from the four evidence-based synopses in routine practice, in accordance with the statements from Hong Kong CMPs (numbered 001–025)  CMPs’ perceived difficulties in applying complex evidence in decision-making (intervention characteristics domain) and ii) inadequate training and limited consultation time (inner setting domain). Facilitators included i) availability of publicly accessible and user-friendly synopses, and ii) formation of community of evidence-based practice among CMPs with input from key opinion leaders (inner setting domain); as well as iii) opportunity for interprofessional collaborations with conventional healthcare providers, and iv) patients’ demand for evidence-based clinical advice (outer setting domain). Besides, i) CMPs’ knowledge and beliefs in EBHC , ii) presentations of evidence-based information in the synopses, and iii) clinical decision making as influenced by quality of evidence reported (intervention characteristics domain) acted as both barriers and facilitators. These factors are likely interdependent. For example, inadequate training and consultation time might negatively affect CMPs’ knowledge level and beliefs in EBHC, which would increase the perceived difficulties in applying complex evidence within limited time.Some barriers identified in our study concurs with previous studies on the use of clinical evidence in routine practice among different healthcare professionals. For instance, physiotherapists and nurses regarded limited resources, in terms of training opportunities and consultation time, as barriers to their adoption of evidence in routine practice , 21. TCIOn the other hand, results of this study showed that evidence was often regarded as a “last resort” to consult, or when the practitioner faces unfamiliar clinical problem. Amongst CMPs in our study, the usefulness of evidence in informing practice is less important than their roles in gaining legitimacy from the health system and conventional healthcare providers, as well as trust from patients , 27. HowThere are some possible strategies targeting CMPs. Existing evidence suggests that education sessions might promote evidence uptake but the effect is expected to be small . The useA number of potential strategies targeting other stakeholders are also suggested. Our results suggested that CMPs might actively adopt evidence in response to patients’ request. This hints the potential usefulness of patient–mediated interventions for promoting evidence uptake. Existing evidence suggests that patient education interventions may enhance healthcare professionals’ adherence to evidence-based clinical practice . In thesCMPs’ current use of evidence in gaining legitimacy from conventional healthcare providers may well be exploited for improving practice via interprofessional collaboration. A recent SR reported that interprofessional interactions was effective in encouraging adherence to evidence-based practice . In healFuture researchers may consider tailoring the aforementioned suggestions into practical implementation strategies , 43. TheWe found the structure and contents of CFIR relevant for our study. This would facilitate the categorization of barriers and facilitators to using results from evidence-based synopses. Our findings also demonstrated the importance of applying such a multifactorial approach to investigate the interdependency and interactions between various determinants in different CFIR domains. Furthermore, we achieved a 100% response rate to invitations in this study. This might be because the participating CMPs were recruited via two investigators’ alumni networks (VCHC and JVHT) in two different Schools of Chinese Medicine in Hong Kong. They would have a higher level of trust in the research team . The parNonetheless, there are some limitations in this study. Firstly, since this study was conducted in Hong Kong, findings might not be generalizable to other health systems. Barriers and facilitators to using results from evidence-based synopses in routine practice identified may not be an exhaustive list of all possible determinants. That said, Hong Kong’s experience in the past two decades may still offer other health systems insights on how to encourage uptake of current clinical evidence in TCIM practice, especially those which are starting to develop TCIM recently. Secondly, since the EBHC approach is the officially endorsed direction for promoting integraton of CM into local health system, social desirability bias may have skewed views on EBHC toward the positive side . CMPs whIn terms of implications, policy makers may consider developing peer learning community among CMPs for promoting EBHC skills acquisition. This can be supplemented by providing up-to-date clinical evidence synopses to enhance evidence implementation in CM. Input from key opinion leaders may facilitate critical interpretation of evidence applicability. The need to respond to patients’ expectations, and interprofessional collaboration opportunities with conventional healthcare providers may also encourage evidence uptake in CM practice. Development of refined implementation strategies in Hong Kong, or in other health systems, would require further input from various key stakeholders, including but not limited to patients, funders, administrators, TCIM and conventional clinicians.This CFIR-based qualitative study investigated how the WHO recommendation of promoting evidence use in routine practice was perceived by CMPs trained in Hong Kong after reunification with China in 1997. The identified barriers to applying clinical evidence synopses in routine practice included i) CMPs’ perceived difficulties in applying complex evidence in decision-making and ii) inadequate training and limited consultation time. The facilitators were i) availability of publicly accessible and user-friendly synopses, ii) formation of community of evidence-based practice among CMPs with input from key opinion leaders, iii) opportunity for interprofessional collaborations with conventional healthcare providers, and iv) patients’ demand for evidence-based clinical advice. Besides, i) CMPs’ knowledge and beliefs in EBHC, ii) presentations of evidence-based information in the synopses and iii) clinical decision making as influenced by quality of evidence reported acted as both barriers and facilitators. Implications from these findings may inform tailoring of implementation strategies in the future, in the context of a well-developed health system with dominance of conventional medicine.Additional file 1.Additional file 2.