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AimMutualistic interactions between plants and animals are fundamental for the maintenance of natural communities and the ecosystem services they provide. However, particularly in human-dominated island ecosystems, introduced species may alter mutualistic interactions. Based on an extensive dataset of plant–frugivore interactions, we mapped and analysed a meta-network across the Caribbean archipelago. Specifically, we searched for subcommunity structure (modularity) and identified the types of species facilitating the integration of introduced species in the Caribbean meta-network.LocationCaribbean archipelago (Lucayan archipelago, Greater Antilles, Lesser Antilles).MethodsWe reviewed published scientific literature, unpublished theses and other nonpeer-reviewed sources to compile an extensive dataset of plant–frugivore interactions. We visualized spatial patterns and conducted a modularity analysis of the cross-island meta-network. We also examined which species were most likely to interact with introduced species: (1) endemic, nonendemic native or introduced species, and (2) generalized or specialized species.ResultsWe reported 3060 records of interactions between 486 plant and 178 frugivore species. The Caribbean meta-network was organized in 13 modules, driven by a combination of functional or taxonomic (modules dominated by certain groups of frugivores) and biogeographical (island-specific modules) mechanisms. Few introduced species or interaction pairs were shared across islands, suggesting little homogenization of the plant–frugivore meta-network at the regional scale. However, we found evidence of “invader complexes,” as introduced frugivores were more likely to interact with introduced plants than expected at random. Moreover, we found generalist species more likely to interact with introduced species than were specialized species.Main conclusionsThese results demonstrate that generalist species and “invader complexes” may facilitate the incorporation of introduced species into plant–frugivore communities. Despite the influx of introduced species, the meta-network was structured into modules related to biogeographical and functional or taxonomic affinities. These findings reveal how introduced species become an integral part of mutualistic systems on tropical islands.1 INTRODUCTIONMutualistic interactions between plants and animals, such as pollinators and frugivores, are critically important for maintaining the functionality of natural communities (Jordano, 1987;Ollerton et al., 2011; Rech et al., 2016). While most flowering plants are dependent on animals for pollination and seed-set (Ollerton et al., 2011; Rech et al., 2016), animal frugivores may ingest or otherwise manipulate and consequently disperse millions of seeds annually (Bueno et al., 2013). Frugivory is thereby crucial for the maintenance of plant diversity (Harms et al., 2000), as it allows plants to populate new sites, maintains gene flow between distinct populations and decreases density-dependent mortality in proximity of the parent individuals (Rogers et al., 2021). In some tropical systems, approximately 90% of all woody plants depend on frugivores for seed dispersal (Almeida-Neto et al., 2008; Howe & Smallwood, 1982). In addition to providing direct dispersal to specific, favourable sites for the plant (Wenny & Levey, 1998), frugivores can enhance the probability of successful germination, for example through the passage of seeds in the intestinal system (e.g. Traveset et al., 2001). The most important frugivore groups are birds, mammals and reptiles with birds and reptiles being particularly important in tropical island ecosystems (Kaiser-Bunbury et al., 2010; Valido & Olesen, 2007).Globally, co-evolved plant–frugivore communities are suffering from an array of drivers associated with global change, such as the introduction of species into new environments, where they become integrated into local communities through species interactions (Gallardo et al., 2016; Vilà et al., 2011). Species communities are thus being altered, which in turn may have consequences for biotic interactions and ecosystem functions, such as seed dispersal (Aslan et al., 2013; Lugo et al., 2012; Traveset & Richardson, 2006; Vizentin-Bugoni et al., 2021). Island ecosystems are particularly vulnerable to the disruption of native plant–frugivore interactions as island mutualists have evolved in isolation, and frequently developed specific traits, such as altered dispersal, or loss of defence traits in plants (Burns, 2019). Furthermore, as islands harbour many endemic species found nowhere else on Earth (Kier et al., 2009; Paulay, 1994), and have experienced disproportionally high extinction rates and numerous extant island species are threatened with extinctions (Blackburn et al., 2004; Fernández-Palacios et al., 2021; Groombridge, 1992), it is especially important to understand how introduced species integrate into island communities (Wood et al., 2017).Introduced species may integrate into existing communities and establish themselves in different ways. For instance, the concept of “invader complexes” suggests that introduced species facilitate the establishment of other introduced species, resulting in groups of introduced species interacting strongly with each other and less with the remaining community (D'Antonio & Dudley, 1993). Alternatively, endemic species that have become superabundant and highly generalized species due to ecological release and density compensation may readily include new arrivals into their interactions and thereby facilitate the establishment of introduced species on islands (Olesen et al., 2002). Furthermore, a growing number of studies show that species with many mutualistic partners (i.e. generalized species irrespectively of being nonendemic native or endemic) are more likely to incorporate new partners into their networks (Bascompte & Stouffer, 2009; Maruyama et al., 2016). In network theory, this is called “preferential attachment” (Newman, 2001), and thus, most generalized species would be expected to interact with introduced species.In addition to understanding which species are responsible for incorporating introduced species into native communities, we have little quantitative understanding of how introduced species affect the structure of native interaction networks and how this varies biogeographically (Fricke & Svenning, 2020). As for other mutualistic networks, plants and frugivores form complex interaction networks with reccurring structural properties (Bascompte & Jordano, 2007). One such property of interaction networks is modularity, which describes how interacting species aggregate into modules consisting of species that interact strongly within the respective module but much less with species of other modules (Thébault, 2013). The modular structure of mutualistic networks may reflect “co-evolutionary units” (Olesen et al., 2007) determined by an array of factors, such as phenological overlap, morphological traits, taxonomic relatedness and biogeography (Araujo et al., 2018; Dalsgaard et al., 2013; Donatti et al., 2011; Martín González et al., 2018; Maruyama et al., 2014; Schleuning et al., 2014). However, it is poorly understood whether introduced species influence the modular structure of mutualistic systems.Here, we present an extensive dataset on plant–frugivore interactions compiled from published and unpublished resources across the islands of the Caribbean archipelago: Lucayan archipelago, Greater Antilles and Lesser Antilles. We use the data to (i) explore the distribution of frugivory records across the Caribbean islands; (ii) assess island connectivity through shared species and interactions; (iii) evaluate the modular structure of the regional plant–frugivore meta-network and (iv) determine whether generalized vs. specialized species and introduced vs. endemic species are more likely to integrate introduced plants and frugivores into native plant–frugivore communities in island systems.2 METHODS2.1 Data collection and study regionAll our data were collected on the Caribbean islands, that is the Lucayan archipelago (The Bahamas and Turks and Caicos), the Greater Antilles (Cuba, Cayman Islands, Jamaica, Hispaniola and Puerto Rico) and the Lesser Antilles (a series of islands from the US and British Virgin Islands in the north to Grenada in the south). We did not include plant–frugivore interactions from islands such as Trinidad and Tobago, Curaçao, and Bonaire just north of South America, as these are continental islands with biotas with strong affinities to the South American mainland (Carstensen et al., 2012; Ricklefs & Bermingham, 2008). The low-lying sedimentary islands of the Lucayan Archipelago are part of the North American platform (Iturralde-Vinent & MacPhee, 1999; Trejo-Torres & Ackerman, 2001), and some of the islands have been interconnected in the Pleistocene (Murphy et al., 2004; Trejo-Torres & Ackerman, 2001). The mostly large and mountainous islands of the Greater Antilles are old with different geological origins (Graham, 2003; Iturralde-Vinent & MacPhee, 1999). The Greater Antilles emerged as fragments in the Eocene about 49 Ma; the geological history of the region has been highly dynamic with some parts connected in the past (Buskirk, 1985; Graham, 2003; Iturralde-Vinent & MacPhee, 1999; Ricklefs & Bermingham, 2008). The current biota of the Greater Antilles was only in small parts formed by vicariance, with dispersal facilitated by the Aves Ridge about 32–35 Ma (Iturralde-Vinent & MacPhee, 1999) or a more likely overwater dispersal at least for the avifauna (Buskirk, 1985; Graham, 2003; Ricklefs & Bermingham, 2008). The Lesser Antilles form a volcanic arc where the North and South American plates subduct under the Caribbean plate and likely originated at least 20 Ma (Ricklefs & Bermingham, 2008). To the east of the volcanic arc are some younger and low-lying islands such as Antigua and Barbuda, which consist of uplifted marine sediments (Ricklefs & Bermingham, 2008; Ricklefs & Lovette, 1999). Some islands were interconnected during the last glacial maximum, but most Lesser Antilles islands have never been interconnected (Ricklefs & Bermingham, 2004, 2008). The isolation of the Caribbean islands from the mainland differs greatly (Carstensen et al., 2012). Bimini in the Bahamas, for instance, is only approx. 87 km from the North American continent and Grenada in the Lesser Antilles is only 137 km from the continental landmass of South America. By contrast, islands such as Grand Turk (993 km) and South Caicos (999 km) are much more isolated from the mainland. On average, the isolation from any continental landmass in the Caribbean is over 500 km (Mean: 593 km ± 248 km SD; see details in Supporting Information Table S1). The distances between single islands are much smaller, for example the distance between Martinique and Dominica and Martinique and Saint Lucia is approx. 40 km. An island size threshold of 10,000 km2 has previously been suggested to be important for islands to be considered sources for colonization (Weigelt & Kreft, 2013), and on average, the islands of the Caribbean are approx. 304 km (±174 km SD) from the nearest island that exceeds 10,000 km2 (Table S1). Given the geological history and isolation of the Caribbean, the biota is characterized by being depauperate with high levels of endemism.To collect data on interactions between plants and frugivores in the Caribbean, we screened the Web of Science (WoS) and Google Scholar search engines. We used the combination of the following search terms: (“frugivory” OR “seed dispersal” OR “seed removal” OR “mutualism”) AND (“Caribbean” OR “Lesser Antilles” OR “Greater Antilles” OR “West Indies” OR “Bahamas” OR “Turks and Caicos” OR “Cayman Islands” OR “Jamaica” OR “Cuba” OR “Hispaniola” OR “Haiti” OR “Dominican Republic” OR “República Dominicana” OR “Puerto Rico” OR “Mona” OR “Virgin Islands” OR “Saint Martin” OR “Anguilla” OR “St. Kitts and Nevis” OR “Antigua” OR “Barbuda” OR “Montserrat” OR “Guadeloupe” OR “Dominica” OR “Martinique” OR “St. Lucia” OR “St. Vincent” OR “Grenadines” OR “Barbados” OR “Grenada”). To also include the grey literature, we contacted local ornithologists and ecologists working in the Caribbean region. This approach allowed us to obtain non-English publications, such as theses and dissertations not available online. We screened each of the studies manually, discarding studies where no appropriate data were presented (e.g. mutualistic interactions in marine environments). Interactions were only included when the respective authors presented original evidence for interaction events, that is evidence of fruits and/or seeds being ingested by frugivores. Thus, we discarded records where interactions between species were speculative (e.g. observation of frugivores on fruiting plant species without any evidence of fruit ingestion).We standardized the species names of plants and frugivores using the R-package taxize (Chamberlain & Szocs, 2013; Global Names Resolver, 2021) and data from the Integrated Taxonomic Information System (ITIS, 2021). We also retrieved information about species taxonomies (i.e. class, order and family) from ITIS. Finally, we compiled information about the native status of species and classified them into nonendemic native (species native to the Caribbean, but also naturally occurring elsewhere), endemic (only occurring within the Caribbean) and introduced (not naturally occurring within Caribbean) species (see details in Supporting Information Text S1). Of the original records, 95 plant (approx. 16% of all reported plants) and one frugivore record were not identified to species level (e.g. only genus name reported) and were thus excluded from data analyses. The final data used in statistical analyses consisted of interactions between 486 plant and 178 frugivore species.2.2 Data analysis2.2.1 Cross-island patterns of shared species and interactionsWe summarized patterns of shared species and interaction pairs across the Caribbean by calculating the proportion of shared species and interaction pairs across all islands. We calculated this proportion as the number of species/interaction pairs found on any two islands, divided by the total number of species/interaction pairs found on the given islands (Fricke & Svenning, 2020). We summarized these patterns separately for all reported records, for endemic, nonendemic native and for introduced plant and frugivore species and interaction pairs, respectively.2.2.2 Modularity of the Caribbean plant–frugivore meta-networkTo detect a modular structure of the meta-network, that is the network of plant–frugivore interactions across all islands, we employed Beckett's DIRT-LPA algorithm in the computeModules function of the R-package “bipartite” (Dormann et al., 2008, 2009). We ran 10 independent runs of the algorithm on the binary meta-network containing interactions between all identified species and identified the run with the single best division into modules, that is the highest degree of modularity Q. For the run with the highest Q value, we recorded the Q value, the number of modules as well as the respective plant and frugivore species in each module (Schleuning et al., 2014) and the islands on which they were recorded. To test whether the identified modular structure of the meta-network differed from random, we compared our results to 100 null models. To this end, we used an algorithm proposed by Patefield (1981) to randomize the interactions between species, using fixed marginal totals to produce networks with randomly associated species without constraining the degree of specialization (Blüthgen et al., 2008; Schleuning et al., 2014). For each of the null models, we applied the same approach as with the original matrix, that is we identified the single best configuration from 10 independent runs (Schleuning et al., 2014). We then tested whether modularity of the original matrix was significantly different from the best 100 null models by looking at the proportion of null modularity values that were greater than the empirical one, that is if .05; Figure S2c) and the frugivore perspective (slope = 0.003, p > .05; Figure S2d).4 DISCUSSIONHere, we present a comprehensive review of published plant–frugivore interactions across the Caribbean archipelago, including the Lucayan archipelago, the Greater and Lesser Antilles. All islands shared species and unique interaction pairs with neighbouring islands and archipelagos, thereby forming a cohesive meta-network. We show that the meta-network of plant–frugivore interactions across the Caribbean was structured into modules, with at least some modules determined by a combination of functional or taxonomic (i.e. certain groups of frugivores) and biogeographical (i.e. island-specific modules) mechanisms. While relatively few species in the dataset were introduced to the Caribbean (16% plant and 8% frugivore species), we found support for the “invader complexes” theory, whereby introduced species facilitate the establishment of other introduced species (D'Antonio & Dudley, 1993; Olesen et al., 2002). Moreover, we found that generalized species were more likely to incorporate introduced species into their interactions, giving support for the “preferential attachment” theory (Newman, 2001). Below, we first discuss the available data on frugivory in the Caribbean, whereafter we discuss how species and interactions are shared across islands. We end by discussing the drivers of modularity and the integration of introduced species into plant–frugivore communities across the Caribbean.4.1 Data on frugivores and their plants in the Caribbean archipelagoAcross all islands, the vast majority of reported frugivores were birds (79%), followed by reptiles (13%) and mammals (8%), of which in turn the majority were bats (71%). These data thus reflect patterns that are typical for oceanic islands, as there is generally a lack of nonvolant, large-bodied, frugivorous mammals which may be ecologically replaced by birds and reptiles (Kaiser-Bunbury et al., 2010). The low number of mammal species in the dataset could also reflect past mammal extinctions particularly on the islands of the Greater Antilles (Turvey et al., 2021), potentially leaving some plants without their main seed dispersers.A large proportion of the plant species (28%) and the majority of frugivore species in the dataset (65%) were classified as endemic to the Caribbean. High degrees of endemism in local species communities are characteristic of island ecosystems (Kier et al., 2009; Paulay, 1994). In a review of plant–frugivore interactions on the Galapagos archipelago, Heleno et al. (2011) found similarly high proportions of endemic frugivores in the species pool (71%), underlining the importance of endemic frugivores for island communities. By contrast, only a few species in the dataset were classified as introduced to the Caribbean (16% plants and 8% frugivores), which was lower than other studies on island ecosystems. Notably on Hawai'i, the proportion of introduced seed disperser species ranged from 50% to 100% for plants and from 60% to 100% for birds (Vizentin-Bugoni et al., 2019). On the Galapagos, the proportion of introduced plants and frugivores was 28% and 23%, respectively (Heleno et al., 2011). However, on the Galapagos, all introduced frugivore species were mammals, whereas in our data, the vast majority of introduced species were birds (86%) and only two species (14%) were mammals (a primate: Chlorocebus pygerythrus and a carnivore: Herpestes javonicus).4.2 Cross-island patterns of shared species and interactionsWhen examining the role of different groups of plants and frugivores in connecting islands and archipelagos, we found that nonendemic native species and interaction pairs were shared most widely across islands (Figure 2), which is expected, as these species are widespread species occurring throughout the Caribbean and the Neotropical mainland. They are thus supposedly good dispersers, and their ranges often occur across multiple islands and cross-borders of archipelagos (Dalsgaard et al., 2014). Although endemic frugivores made up more than 60% of the frugivore species, generally they overlapped much less between islands compared to nonendemic natives, which only accounted for less than 30% of the frugivores in the data (Table 2). This pattern is not surprising, since the distributional ranges of endemic species are per definition confined within limited geographical areas (Kricher, 2011), many species being single-island endemics or occurring on few islands within each of the archipelagoes, that is the Lucayan archipelago, the Greater and Lesser Antilles (Dalsgaard et al., 2014). In the Caribbean, for instance, there is a high number of single-island endemic frugivorous birds, such as various species of parrots like the Saint Vincent Parrot Amazona guildingii (Birds Caribbean, 2021). Introduced plant species were shared widely across the Caribbean (Figure 2), which was expected, as most were agricultural and widely cultivated plants, reflecting that the Caribbean is historically heavily impacted by humans (Kemp et al., 2020; Walters & Hansen, 2013). By contrast, introduced frugivores were reported on few islands only (Table 2), and these islands shared mostly low proportions of introduced frugivores (Table S4); introduced interaction pairs were almost not shared between islands. Globally, a recent study showed how introduced species caused an increase in the proportion of regions sharing species and interactions (Fricke & Svenning, 2020), demonstrating that species introductions led to increasing similarity and homogenization in plant–frugivore communities across the world (Fricke & Svenning, 2020). In the Caribbean, however, given our data, especially nonendemic natives played a bigger role in interconnecting islands.4.3 Modularity of the Caribbean plant–frugivore meta-networkThe Caribbean plant–frugivore meta-network was organized in modules, as are most mutualistic plant–animal interaction networks, both local networks (e.g. Dalsgaard et al., 2013; Dupont & Olesen, 2009; Mello et al., 2011a, 2011b; Olesen et al., 2007) and meta-networks (Araujo et al., 2018; Emer et al., 2018; Martín González et al., 2018). The separation of the meta-network into modules was at least partly driven by functional or taxonomic (i.e. modules dominated by certain species groups) and biogeographical (i.e. island-specific modules) mechanisms. For instance, one module consisted of small- to medium-sized bird species recorded in Jamaica (100% birds; 88% of frugivores recorded in Jamaica; module nine in Figure 4). Another module consisted mostly of various bat species (63% bats) recorded in Cuba (88% of frugivores recorded in Cuba; module one in Figure 4), whereas another module consisted almost exclusively of rock iguanas (Cychlura spp.) found in the Bahamas only (88% Iguanas; 88% of frugivores were recorded on the Bahamas only; module 13 in Figure 4). These modules associated with specific functional/taxonomic groups or specific islands were thus positioned in the periphery of the Caribbean meta-network (Figure 3). The separation into modules according to biogeographical affinities, such as single islands, was expected given that interactions between plants and frugivores are inherently spatial as species must be in the same place to interact (Morales & Vázquez, 2008) and many species are restricted to specific islands. Spatial patterns that correspond to insularity in the broad sense have previously been shown to partially explain the modular structure of mutualistic plant–animal networks in landscape matrices, where species are restricted to different types of patchily distributed habitats (Maruyama et al., 2014). Patterns of modularity have also previously been suggested to be explained by behavioural or functional traits of species (Dicks et al., 2002; Donatti et al., 2011; Maruyama et al., 2014). In plant–frugivore interactions, although plants typically aim to attract functionally diverse seed dispersers (Plein et al., 2013), there is evidence of functional matching between interaction partners, especially with birds (Vollstädt et al., 2017). Morphologically different frugivore species tend to forage on morphologically distinct sets of plant species (Dehling et al., 2016; Gautier-Hion et al., 1985; Lomáscolo et al., 2010; Mello et al., 2011b), which might be reflected in the modules composed primarily of specific frugivore groups with characteristic morphological and functional traits. Bats, for instance, consume different types of fruits than birds and may show a clear separation in their dietary composition (Gorchov et al., 1995). The patterns of modularity we detected were therefore in line with expectations of functional/taxonomic and biogeographical mechanisms as drivers of modularity. However, there were also modules consisting of a mix of species from various islands. One module consisted of about 50% of large parrot species (Amazona spp.), but the frugivores were recorded in the entire Caribbean (module six in Figure 4) and, notably, the module in the centre of the Caribbean meta-network consisted of various types of frugivores occurring throughout the Caribbean, thereby interconnecting islands and archipelagos in the Caribbean meta-network (module seven; Figure 3 and Table S5).4.4 Interactions with introduced speciesRegarding how introduced species were integrated into the meta-network, we found that nonendemic native and endemic plants and frugivores interacted significantly less with introduced frugivore species than expected at random (Figure 4a,b). Among Caribbean frugivores and their fruiting plants, there is therefore no support for the idea that endemic super-generalists are the main facilitators of introduced species, as suggested for pollination networks on tropical islands (Olesen et al., 2002). On the contrary, introduced frugivores were recorded interacting with introduced plants significantly more often than expected at random (Figure 4c). This pattern suggests that introduced frugivores “prefer” to feed on introduced plants, which in turn suggests the presence of “invader complexes,” that is introduced species interacting more among themselves than expected at random, thus facilitating their establishment (D'Antonio & Dudley, 1993). Such facilitation processes between introduced species can lead to “invasional meltdowns,” as large groups of introduced species may have increasingly negative impacts on native communities (Jeschke et al., 2012; Simberloff & von Holle, 1999). Other island ecosystems have been found to be even more dominated by introduced frugivores, notably Hawai'i is almost exclusively dominated by introduced frugivores, as most of the endemic species have gone extinct (Vizentin-Bugoni et al., 2019; Vizentin-Bugoni et al., 2021). These findings from various archipelagos are concerning, regarding the potential impact of introduced species on native ecosystems. Such findings are particularly worrying when considering that on other island ecosystems, introduced species were also more often involved in seed-dispersal interactions (rather than seed/pulp predation) than native species (Heleno et al., 2011; Vizentin-Bugoni et al., 2019, 2021). For many of the interaction records, our data do not distinguish between seed-dispersal interactions or seed/pulp predation events; thus, it is not possible to estimate the effect of introduced species on local native and endemic plant communities in the Caribbean. Nevertheless, in Hawai'i, it was shown that introduced frugivores do not sufficiently replace the species roles of lost seed dispersers, since they preferentially disperse seeds of introduced rather than native plants (Vizentin-Bugoni et al., 2019). This raises the question why introduced plant species seem so attractive. One reason could be that introduced plants may have specific traits, such as longer fruiting duration, which increase the probability of encounters and are therefore more likely to be consumed by frugivores (Heleno et al., 2011; Sperry et al., 2021). In the Caribbean meta-network, many of the observations were from agricultural areas, where agricultural plants such as Mangifera indica (Mango) are often abundant with large crops, and although they are not dispersed by any native frugivore, they do overall attract many frugivores. Fruiting plant and thus resource abundance is in turn linked to increased fruit consumption, because frugivores often track available fruits in the landscape (Quitián et al., 2019), and consequently, the patterns we find may be partially driven by the high abundance of introduced agricultural plants and their crop sizes in human-dominated environments. Such patterns may be more pronounced on densely populated islands than on islands with few people and relatively more protected areas.In addition to “invader complexes,” we found that generalist species, that is species with many interaction partners, were more likely to interact with introduced species, which was consistent for both plants and frugivores (Figure S2a,b). These results are in line with previous findings, underlining the importance of highly generalized species for the establishment of introduced species, especially on islands (Maruyama et al., 2016). This gives support for the “preferential attachment” hypothesis (Newman, 2001), that is that species with wide ecological niches include and facilitate the establishment of new species, such as introduced species on islands. Our finding that generalized species do not have a higher proportion of interactions with introduced partners in their total set of interactions than specialized species (Figure S2c,d) reflects the overall low numbers of introduced species in the Caribbean data. Since only few of the potentially available interaction partners are introduced species, generalized species with many interaction partners would also be expected to have a decreasing proportion of their interactions with introduced species. Thus, although generalized species are likely to incorporate introduced species into their niche (Figure S2a,b), they do not have a specific preference for introduced species (Figure S2c,d).5 CONCLUSIONSBased on a comprehensive review of accessible data on plant–frugivore interactions, we showed that the Caribbean meta-network is structured into modules and demonstrate how introduced species are integrated into native communities in the Caribbean archipelago. These results provide valuable insight into plant–frugivore interactions in insular biodiversity hotspots, showing how insular plant–frugivore systems are susceptible to invasion. Future studies are needed to demonstrate the importance of introduced species as seed dispersers compared with seed/pulp predators (Nogales et al., 2017). Specifically, research quantifying the relative importance of different frugivore groups as seed dispersers and their respective effectiveness is lacking for most plant–frugivore interactions in the Caribbean. This would provide valuable information and could help with the conservation of endemic plants in the Caribbean archipelago. Moreover, we also in general lack information on frugivory in the Caribbean. Kim et al. (2022) reported 4336 species of plants with animal-dispersal syndromes in the Caribbean archipelago, and our dataset represents only 11% of those species with some regional variation (Table S6). For instance, whereas Puerto Rican plants were covered relatively well (31% of the species), plants in Hispaniola (approx. 7%), Jamaica (approx. 8%) and the Lesser Antilles (approx. 9%) were less well represented. There may also be taxonomical differences in sampling completeness. Palms (Arecaceae) are highly diverse in the Caribbean representing 135 species (Roncal et al., 2008), and our dataset had only 23 palm species (17%). Several endemic and highly threatened fleshy-fruited plants do not have any information on the main seed dispersers (e.g. Catesbea spinosa, Brunfelsia portoricensis, Diospyros spp. and many cactus species). We also have limited and incomplete information on the fruit diet of several endemic frugivores (e.g. pigeons, thrashers and thrushes) that could play an important role for seed dispersal of Caribbean plants. There is therefore an urgent need to increment more scientific information on plant–frugivore interactions in the Caribbean, one of the world's insular biodiversity hotspots.ACKNOWLEDGEMENTSThis work is dedicated to our colleague and coauthor Michel Faife-Cabrera who passed away due to Covid-19 complications. M. Galetti thanks CNPq and University of Miami for financial support. M.G.R. Vollstädt, C. N. Kaiser-Bunbury, B. I. Simmons, F. Gonçalves, and B. Dalsgaard thank the Independent Research Fund Denmark (grant no. 0135-00333B). Funding for A. Strong's work was provided by an NSF grant to T. W. Sherry (Tulane University) and R. T. Holmes (Dartmouth College), the Chicago Zoological Society, Sigma Xi Grants-in-Aid-of Research, the World Nature Association, and The Louisiana Educational Quality Support Fund. A. Strong's work benefitted from collaborations with M. Johnson, T. Sherry, A. Sutton and the late R. Sutton. Funding for S. Schubert's work was provided by Rufford Foundation Small Grants 1, 2, & Booster, in addition to the Old Dominion University Paul W. Kirk Jr Student Research Award, a British Ornithologists' Union Student Research Award, and the BirdsCaribbean David S. Lee Fund. J. Salazar's work was funded by FONDOCyT. (Ministerio de Educaciòn Superior, Ciencia y Tecnología), Project 1B4-9. F. L. Tarazona-Tubens is supported by McKight Fellowship. B. I. Simmons was supported by a Royal Commission for the Exhibition of 1851 Research Fellowship. We also thank all researchers who have worked intensively in the Caribbean.CONFLICT OF INTERESTThe authors declare that there is no conflict of interest to report.Open ResearchSupporting InformationREFERENCESBIOSKETCHMaximilian Vollstädt is an ecologist, and a researcher at the University of Copenhagen, Denmark. His research interests include mutualistic interactions in plant-pollinator and plant-seed disperser communities in tropical island ecosystems.Author contributions: M.G.R.V., M.G., B.D. Conceptualization, Methodology; M.G.R.V., B.I.S. Formal analysis, Visualization; M.G.R.V., M.G., C.N.K.B., B.D. Original draft preparation, Writing; All Authors: Writing, Review & Editing.Volume28, Issue11November 2022Pages 2361-2374FiguresReferencesRelatedInformationRecommendedNatural mixing of species: novel plant–animal communities on Caribbean IslandsA. E. Lugo, T. A. Carlo, J. M. WunderleAnimal ConservationFrugivore distributions are associated with plant dispersal syndrome diversity in the Caribbean archipelagosSeokmin Kim, Lilian Sales, Daiane Carreira, Mauro GalettiDiversity and DistributionsInteractions between resource availability and enemy release in plant invasionDana M. BlumenthalEcology LettersHuman disturbances affect the topology of food websFrederico Mestre, Alejandro Rozenfeld, Miguel B. AraújoEcology LettersA general framework for species-abundance distributions: Linking traits and dispersal to explain commonness and rarityThomas Koffel, Kaito Umemura, Elena Litchman, Christopher A. Klausmeier

This issue of Transcultural Psychiatry showcases some recent work on idioms of distress – the latest in a long line of anthropological research concerned with cross-cultural concepts and experiences of distress.() Mark Nichter’s (1981) seminal paper introducing idioms of distress has become a cynosure for psychological anthropology and transcultural psychiatry. A growing body of work has since accumulated; however, the last time a collection of such research was brought together was the 2010 publication of a special issue in the journal Culture, Medicine and Psychiatry organized by Devon Hinton and Roberto Lewis-Fernández. In the decade since, new questions have arisen about the boundaries and applications of idioms of distress research. In this introduction, we provide a brief history of work on idioms of distress and related concepts. Then, we introduce several major themes explored by the papers in this special issue.

Effective conservation of ecological communities requires accurate and up-to-date information about whether species are persisting or declining to extinction. The persistence of an ecological community is supported by its underlying network of species interactions. While the persistence of the network supporting the whole community is the most relevant scale for conservation, in practice, only small subsets of these networks can be monitored. There is therefore an urgent need to establish links between the small snapshots of data conservationists can collect, and the “big picture” conclusions about ecosystem health demanded by policymakers, scientists, and societies. Here, we show that the persistence of small subnetworks (motifs) in isolation—that is, their persistence when considered separately from the larger network of which they are a part—is a reliable probabilistic indicator of the persistence of the network as a whole. Our methods show that it is easier to detect if an ecological community is not persistent than if it is persistent, allowing for rapid detection of extinction risk in endangered systems. Our results also justify the common practice of predicting ecological persistence from incomplete surveys by simulating the population dynamics of sampled subnetworks. Empirically, we show that our theoretical predictions are supported by data on invaded networks in restored and unrestored areas, even in the presence of environmental variability. Our work suggests that coordinated action to aggregate information from incomplete sampling can provide a means to rapidly assess the persistence of entire ecological networks and the expected success of restoration strategies.

In their response to our article (both in this issue), DeYoung and colleagues did not sufficiently address three fundamental flaws with the Hierarchical Taxonomy of Psychopathology (HiTOP). First, HiTOP was created using a simple-structure factor-analytic approach, which does not adequately represent the dimensional space of the symptoms of psychopathology. Consequently, HiTOP is not the empirical structure of psychopathology. Second, factor analysis and dimensional ratings do not fix the problems inherent to descriptive (folk) classification; self-reported symptoms are still the basis on which clinical judgments about people are made. Finally, HiTOP is not ready to use in real-world clinical settings. There is currently no empirical evidence demonstrating that clinicians who use HiTOP have better clinical outcomes than those who use the Diagnostic and Statistical Manual of Mental Disorders ( DSM). In sum, HiTOP is a factor-analytic variation of the DSM that does not get the field closer to a more valid and useful taxonomy.

Background Community Advisory Boards (CABs) have been frequently used to engage diverse partners to inform research projects. Yet, evaluating the quality of engagement has not been routine. We describe a multi-method ethnographic approach documenting and assessing partner engagement in two “virtual” CABs, for which we conducted all meetings remotely. Methods Two research projects for increasing equitable COVID-19 testing, vaccination, and clinical trial participation for underserved communities involved remote CAB meetings. Thirty-three partners representing 17 community groups participated in 15 sessions across the two CABs facilitated by a social change organization. We developed ethnographic documentation forms to assess multiple aspects of CAB member engagement (e.g., time spent speaking, modality used, types of interactions). Documenters were trained to observe CAB sub-groups via virtual sessions. Debriefing with the documentation team after CAB meetings supported quality assurance and process refinement. CAB members completed a brief validated survey after each meeting to assess the quality and frequency of engagement. Content and rapid thematic analysis were used to analyze documentation data. Quantitative data were summarized as frequencies and means. Qualitative and quantitative findings were triangulated. Results A total of 4,540 interactions were identified across 15 meetings. The most frequent interaction was providing information (44%), followed by responding (37–38%). The quality and frequency of stakeholder engagement were rated favorably (average 4.7 of 5). Most CAB members (96%) reported good/excellent engagement. Specific comments included appreciation for the diversity of perspectives represented by the CAB members and suggestions for improved live interpretation. Debriefing sessions led to several methodological refinements for the documentation process and forms. Conclusion We highlight key strategies for documenting and assessing community engagement. Our methods allowed for rich ethnographic data collection that refined our work with community partners. We recommend ongoing trainings, including debriefing sessions and routinely reviewed assessment of data to strengthen meaningful community engagement.

As the COVID‐19 pandemic continues to affect societies across the world, the ongoing economic and social disruptions are likely to present fundamental challenges for current and future biodiversity conservation.We review the literature for outcomes of past major societal, political, economic and zoonotic perturbations on biodiversity conservation, and demonstrate the complex implications of perturbation events upon conservation efforts. Building on the review findings, we use six in‐depth case studies and the emerging literature to identify positive and negative outcomes of the COVID‐19 pandemic, known and anticipated, for biodiversity conservation efforts around the world.A number of similarities exist between the current pandemic and past perturbations, with experiences highlighting that the pandemic‐induced declines in conservation revenue and capacity, livelihood and trade disruptions are likely to have long‐lasting and negative implications for biodiversity and conservation efforts.Yet, the COVID‐19 pandemic also brought about a global pause in human movement that is unique in recent history, and may yet foster long‐lasting behavioural and societal changes, presenting opportunities to strengthen and advance conservation efforts in the wake of the pandemic. Enhanced collaborations and partnerships at the local level, cross‐sectoral engagement, local investment and leadership will all enhance the resilience of conservation efforts in the face of future perturbations. Other actions aimed at enhancing resilience will require fundamental institutional change and extensive government and public engagement and support if they are to be realised.The pandemic has highlighted the inherent vulnerabilities in the social and economic models upon which many conservation efforts are based. In so doing, it presents an opportunity to reconsider the status quo for conservation, and promotes behaviours and actions that are resilient to future perturbation. A free Plain Language Summary can be found within the Supporting Information of this article., A free Plain Language Summary can be found within the Supporting Information of this article.

Background There are ongoing methodological advances in measuring mental health in humanitarian crises. This Special Section describes numerous innovations. Here we take a practitioner's view in understanding the key issues related to assessment of mental health in humanitarian contexts and how the innovations contribute to the field. Main body In this guide for practitioners, we address the following issues: (1) clarifying the intended purpose of conducting mental health assessment in humanitarian crises: why is this information collected and for what intended purposes?; (2) determining what type of tool should be selected and the types of psychometric properties that are important for tools serving this particular purpose; (3) when a validated tool is not available, considering how qualitative and quantitative methods should be used to generate information on validity; and finally, (4) how to report on validity and its implications for interpreting information for humanitarian practitioners, governments, care providers, and other stakeholders supporting people affected by humanitarian emergencies. Conclusion Ultimately, mental health assessment tools are not independent of the group with which they were designed, nor are the psychometric properties of the tools or their utility universal across purposes. Therefore, organizations and stakeholders will optimize their positive impact when choosing tools wisely, appropriately adapting and validating tools, and providing guidance on how to interpret those findings to best serve populations in need.

Anthropologists have long emphasized the social significance of foods and the contexts in which they are consumed. Expanding on this idea, we define the context of consumption as the non-eating behaviors that surround eating, such as the manner of food preparation, food sharing, and dietary patterns. In this study, we used cultural consensus analysis to assess whether there exist consistently shared, normative ideas about preferable context of food consumption in three diverse research sites: urban Ethiopia, rural Brazil, and rural Haiti. Our analysis demonstrates that in all three communities, there are distinct sets of behaviors that people identified as non-preferable because they reliably associate them with poverty and food insecurity, and behaviors that people identify as preferable because they reliably associate them with wealth and food security. Across the settings, there was little variation in agreement about behaviors across household composition, age, gender, and food security status. These findings suggest that people do indeed share culturally specific ideas about the context in which foods should be prepared and consumed, beyond the actual content of one's diet. Exploring these cultural models elucidates the social consequences of food insecurity, enabling researchers to better examine the relationship between food insecurity, social context, and well-being.

Multiple US states recently passed laws mandating health insurance coverage for fertility preservation (FP) services to improve access to care for patients with cancer, for whom FP service expenses can be prohibitive. Key unanswered questions include how heterogeneous benefit mandate laws and regulations are and how this variation may affect implementation, access, and utilization.To describe the design of state-level FP health insurance benefit mandate laws and regulations and derive guidance on best practices and implementation needs.Legal mapping and implementation science framework-guided analyses were conducted on 11 US state laws that mandate health insurance benefit coverage for FP services for patients at risk of iatrogenic infertility from medical treatments and on related insurer regulations. Design features of laws and regulations and the implementation process were summarized by themes (eg, coverage specification).State jurisdiction.Main outcomes were the scope and specificity of mandated FP insurance coverage and the role of clinical practice guidelines and insurer regulations in implementation.Between June 2017 and March 2021, 11 states passed FP benefit mandate laws. States took a median (range) of 283 (0-640) days to implement mandates, and a majority issued regulatory guidance after the law was in effect. While standard-of-care procedures such as embryo cryopreservation require medical evaluation, medications, ultrasonography and laboratory monitoring, oocyte retrieval, embryo derivation, cryopreservation, and storage, there was variation in which services were specified for inclusion or exclusion in the laws and/or regulator guidance. The majority of state laws and regulator guidance reference medical society clinical practice guidelines and federal policies (Affordable Care Act and Health Insurance Portability and Accountability Act).In this qualitative assessment of 11 state-level FP benefit mandates, variation that may influence patient access was identified in the design and implementation of the mandates. As clinical stakeholders aim to understand and/or shape these laws and their implementation, key considerations included specificity and flexibility of benefit design to be clinically meaningful, expansion of clinical practice guidelines to inform benefit coverage, inclusion of publicly insured and self-insured populations for universal access, and consistency between state and federal policies.

Background There are increasing initiatives to reduce mental illness stigma among primary care providers (PCPs) being trained in mental health services. However, there is a gap in understanding how stigma reduction initiatives for PCPs produce changes in attitudes and clinical practices. We conducted a pilot randomized controlled trial of a stigma reduction intervention in Nepal: REducing Stigma among HealthcAre Providers (RESHAPE). In a previous analysis of this pilot, we described differences in stigmatizing attitudes and clinical behaviors between PCPs receiving a standard mental health training (mental health Gap Action Program, mhGAP) vs. those receiving an mhGAP plus RESHAPE training. The goal of this analysis is to use qualitative interview data to explain the quantitative differences in stigma outcomes identified between the trial arms. Methods PCPs were randomized to either standard mental health training using mhGAP led by mental health specialists or the experimental condition (RESHAPE) in which service users living with mental illness shared photographic recovery narratives and participated in facilitated social contact. Qualitative interviews were conducted with PCPs five months post-training (n = 8, standard mhGAP training; n = 20, RESHAPE). Stigmatizing attitudes and clinical practices before and after training were qualitatively explored to identify mechanisms of change. Results PCPs in both training arms described changes in knowledge, skills, and confidence in providing mental healthcare. PCPs in both arms described a positive feedback loop, in which discussing mental health with patients encouraged more patients to seek treatment and open up about their illness, which demonstrated for PCPs that mental illness can be treated and boosted their clinical confidence. Importantly, PCPs in the RESHAPE arm were more likely to describe a willingness to treat mental health patients and attributed this in part to social contact with service users during the training. Conclusions Our qualitative research identified testable mechanisms of action for stigma reduction and improving clinical behavior: specifically, recovery stories from service users and social engagement led to greater willingness to engage with patients about mental illness, triggering a feedback loop of more positive experiences with patients who benefit from mental healthcare, which further reinforces willingness to deliver mental healthcare. Trial registration ClinicalTrials.gov identifier, NCT02793271

Effective conservation of ecological communities requires accurate and up-to-date information about whether species are persisting or declining to extinction. The persistence of ecological communities is largely supported by its structured architecture of species interactions, known as an ecological network. While the persistence of the network supporting the whole community is the most relevant scale for conservation, in practice, we can only monitor small subsets of these networks due to logistical sampling constraints. There is therefore an urgent need to establish links between the small snapshots of data conservationists are able to collect, and the ‘big picture’ conclusions about ecosystem health demanded by policy makers, scientists and societies. Here we show that the persistence of small subnetworks in isolation — that is, their persistence when considered separately from the larger network of which they are a part — is a reliable probabilistic indicator of the persistence of the network as a whole. Our results are general across both antagonistic and mutualistic interaction networks. Empirically, we show that our theoretical predictions are supported by data on invaded networks in restored and unrestored areas, even in the presence of environmental variability. Our work suggests that coordinated action to aggregate information from incomplete sampling can provide a means to rapidly assess the persistence of entire ecological networks and the expected success of restoration strategies. This could significantly improve our ability to monitor progress towards achieving policy targets, such as those enshrined in the UN Convention on Biological Diversity.

Research on mental health in specific communities requires careful attention to cultural context and language. Studies on global mental health have increasingly analyzed idioms of distress, or culturally situated ways of conceptualizing, experiencing, and expressing distress. This study examines how idioms of distress are used and understood in Arcahaie, Haiti. The goal was to enrich current understanding of mental health conceptualization and communication by exploring the heterogeneity of common idioms of distress. Interviews with community members ( N = 47) explored meanings and perceived causations of 13 idioms of distress. Major themes included pervasiveness of poverty, ruminative thinking, effects of Vodou and Christian belief systems, embodied distress, and the behavior of “crazy” people ( moun fou). The findings suggest some specific pathways for potential community engagement projects, including training lay-leaders in cognitive behavioral therapy using existing socioreligious infrastructure and expanding access to social engagement activities. This research contributes to a small but growing body of literature on mental illness in Haiti and to methods for studying idioms of distress.

Chickpea is the second-most-cultivated legume globally, with India and Australia being the two largest producers. In both of these locations, the crop is sown on residual summer soil moisture and left to grow on progressively depleting water content, finally maturing under terminal drought conditions. The metabolic profile of plants is commonly, correlatively associated with performance or stress responses, e.g., the accumulation of osmoprotective metabolites during cold stress. In animals and humans, metabolites are also prognostically used to predict the likelihood of an event (usually a disease) before it occurs, e.g., blood cholesterol and heart disease. We sought to discover metabolic biomarkers in chickpea that could be used to predict grain yield traits under terminal drought, from the leaf tissue of young, watered, healthy plants. The metabolic profile (GC-MS and enzyme assays) of field-grown chickpea leaves was analysed over two growing seasons, and then predictive modelling was applied to associate the most strongly correlated metabolites with the final seed number plant−1. Pinitol (negatively), sucrose (negatively) and GABA (positively) were significantly correlated with seed number in both years of study. The feature selection algorithm of the model selected a larger range of metabolites including carbohydrates, sugar alcohols and GABA. The correlation between the predicted seed number and actual seed number was R2 adj = 0.62, demonstrating that the metabolic profile could be used to predict a complex trait with a high degree of accuracy. A previously unknown association between D-pinitol and hundred-kernel weight was also discovered and may provide a single metabolic marker with which to predict large seeded chickpea varieties from new crosses. The use of metabolic biomarkers could be used by breeders to identify superior-performing genotypes before maturity is reached.

The Hierarchical Taxonomy of Psychopathology (HiTOP) uses factor analysis to group self-reported symptoms of mental illness (i.e., like goes with like). It is hailed as a significant improvement over other diagnostic taxonomies. However, the purported advantages and fundamental assumptions of HiTOP have received little, if any, scientific scrutiny. We critically evaluated five fundamental claims about HiTOP. We conclude that HiTOP does not demonstrate a high degree of verisimilitude and has the potential to hinder progress on understanding the etiology of psychopathology. It does not lend itself to theory building or taxonomic evolution, and it cannot account for multifinality, equifinality, or developmental and etiological processes. In its current form, HiTOP is not ready to use in clinical settings and may result in algorithmic bias against underrepresented groups. We recommend a bifurcation strategy moving forward in which the Diagnostic and Statistical Manual of Mental Disorders is used in clinical settings while researchers focus on developing a falsifiable theory-based classification system.

Caring for, raising, and educating orphaned and separated children (OSC) is important work that is critical to the long-term well-being of those children. Despite the importance of caregiving, it can be overwhelming and stressful. Much of the available literature addresses the burdens of caregiving, without addressing the positive characteristics that caregivers need to deliver care in residences for OSC. This study’s objective was to identify the desirable characteristics of caregivers through qualitative interviews with directors of residences for OSC across four countries: Cambodia, Ethiopia, India and Kenya. A total of 28 interviews were conducted in the directors’ local languages. Interviews were transcribed, translated into English, and analyzed using NVivo software. A thematic analysis of the data yielded three domains: personal qualities, skills, and religion. Across all the study geographic regions, most participants looked for similar characteristics in caregivers, such as love, patience, teamwork and communication skills, especially communicating about difficult child behaviors. These findings can inform plans to enhance effective and sustainable caregiving at residential care sites for OSC and simultaneously benefit the well-being of caregivers. Residential care directors may consider organizing workshops on teamwork and communication skills that will help improve the quality of caregiving.

The study of mutualistic interaction networks has led to valuable insights into ecological and evolutionary processes. However, our understanding of network structure may depend upon the temporal scale at which we sample and analyze network data. To date, we lack a comprehensive assessment of the temporal scale-dependence of network structure across a wide range of temporal scales and geographic locations. If network structure is temporally scale-dependent, networks constructed over different temporal scales may provide very different perspectives on the structure and composition of species interactions. Furthermore, it remains unclear how various factors – including species richness, species turnover, link rewiring and sampling effort – act in concert to shape network structure across different temporal scales. To address these issues, we used a large database of temporally-resolved plant–pollinator networks to investigate how temporal aggregation from the scale of one day to multiple years influences network structure. In addition, we used structural equation modeling to explore the direct and indirect effects of temporal scale, species richness, species turnover, link rewiring and sampling effort on network structural properties. We find that plant–pollinator network structure is strongly temporally-scale dependent. This general pattern arises because the temporal scale determines the degree to which temporal dynamics (i.e. phenological turnover of species and links) are included in the network, in addition to how much sampling effort is put into constructing the network. Ultimately, the temporal scale-dependence of our plant–pollinator networks appears to be mostly driven by species richness, which increases with sampling effort, and species turnover, which increases with temporal extent. In other words, after accounting for variation in species richness, network structure is increasingly shaped by its underlying temporal dynamics. Our results suggest that considering multiple temporal scales may be necessary to fully appreciate the causes and consequences of interaction network structure. Fil: Schwarz, Benjamin. Albert Ludwigs University of Freiburg; Alemania Fil: Vazquez, Diego P.. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto Argentino de Investigaciones de las Zonas Áridas. Provincia de Mendoza. Instituto Argentino de Investigaciones de las Zonas Áridas. Universidad Nacional de Cuyo. Instituto Argentino de Investigaciones de las Zonas Áridas; Argentina Fil: Cara Donna, Paul J.. Chicago Botanic Garden; Estados Unidos Fil: Knight, Tiffany M.. German Centre for Integrative Biodiversity Research; Alemania Fil: Benadi, Gita. Albert Ludwigs University of Freiburg; Alemania Fil: Dormann, Carsten F.. Albert Ludwigs University of Freiburg; Alemania Fil: Gauzens, Benoit. German Centre for Integrative Biodiversity Research; Alemania Fil: Motivans, Elena. German Centre for Integrative Biodiversity Research; Alemania Fil: Resasco, Julian. University of Colorado; Estados Unidos Fil: Blüthgen, Nico. Universitat Technische Darmstadt; Alemania Fil: Burkle, Laura A.. Montana State University; Alemania Fil: Fang, Qiang. Henan University of Science and Technology; China Fil: Kaiser Bunbury, Christopher N.. University of Exeter; Reino Unido Fil: Alarcón, Ruben. California State University; Estados Unidos Fil: Bain, Justin A.. Chicago Botanic Garden; Estados Unidos Fil: Chacoff, Natacha Paola. Universidad Nacional de Tucumán. Instituto de Ecología Regional. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Tucumán. Instituto de Ecología Regional; Argentina Fil: Huang, Shuang Quan. Central China Normal University; China Fil: LeBuhn, Gretchen. San Francisco State University; Estados Unidos Fil: MacLeod, Molly. Rutgers University; Estados Unidos Fil: Petanidou, Theodora. Univversity of the Aegean; Estados Unidos Fil: Rasmussen, Claus. University Aarhus; Dinamarca Fil: Simanonok, Michael P.. Montana State University; Estados Unidos Fil: Thompson, Amibeth H.. German Centre for Integrative Biodiversity Research; Alemania Fil: Fründ, Jochen. Albert Ludwigs University of Freiburg; Alemania

INTRODUCTION: Despite extensive ethnographic and qualitative research on traditional healers in Nepal, the role of traditional healers in relation to mental health has not been synthesized. METHODS: We focused on the following clinically based research question, “What are the processes by which Nepali traditional healers address mental well-being?” We adopted a scoping review methodology to maximize the available literature base and conducted a modified thematic analysis rooted in grounded theory, ethnography, and phenomenology. We searched five databases using terms related to traditional healers and mental health. We contacted key authors and reviewed references for additional literature. RESULTS: Our scoping review yielded 86 eligible studies, 65 of which relied solely on classical qualitative study designs. The reviewed literature suggests that traditional healers use a wide range of interventions that utilize magico-religious explanatory models to invoke symbolic transference, manipulation of local illness narratives, roles, and relationships, cognitive restructuring, meaning-making, and catharsis. DISCUSSION: Traditional healers’ perceived impact appears greatest for mild to moderate forms of psychological distress. However, the methodological and sample heterogeneity preclude uniform conclusions about traditional healing. Further research should employ methods which are both empirically sound and culturally adapted to explore the role of traditional healers in mental health.

Background The soil environment is responsible for sustaining most terrestrial plant life, yet we know surprisingly little about the important functions carried out by diverse microbial communities in soil. Soil microbes that inhabit the channels of decaying root systems, the detritusphere, are likely to be essential for plant growth and health, as these channels are the preferred locations of new root growth. Understanding the microbial metagenome of the detritusphere, and how it responds to agricultural management such as crop rotations and soil tillage, is vital for improving global food production. Results This study establishes an in-depth soil microbial gene catalogue based on the living-decaying rhizosphere niches in a cropping soil. The detritusphere microbiome regulates the composition and function of the rhizosphere microbiome to a greater extent than plant type: rhizosphere microbiomes of wheat and chickpea were homogenous (65–87% similarity) in the presence of decaying root (DR) systems but were heterogeneous (3–24% similarity) where DR was disrupted by tillage. When the microbiomes of the rhizosphere and the detritusphere interact in the presence of DR, there is significant degradation of plant root exudates by the rhizosphere microbiome, and genes associated with membrane transporters, carbohydrate and amino acid metabolism are enriched. Conclusions The study describes the diversity and functional capacity of a high-quality soil microbial metagenome. The results demonstrate the contribution of the detritusphere microbiome in determining the metagenome of developing root systems. Modifications in root microbial function through soil management can ultimately govern plant health, productivity and food security.

PurposeOncofertility care for pediatric, adolescent, and young adult cancer patients remains under-implemented across adult and pediatric oncology settings. We pilot tested an electronic health record (EHR)-enabled multi-component oncofertility intervention (including screening, referral, and fertility consult) in an adult academic oncology program and systematically assessed intervention fit to pediatric and community oncology programs.MethodsUsing surveys (n=33), audits (n=143), and interviews (n=21) guided by implementation science frameworks, we pilot tested the EHR-enabled intervention for oncofertility care in young cancer patients at an adult oncology program and evaluated implementation outcomes. We interviewed healthcare providers from seven regional oncology and fertility programs about intervention fit to their clinical contexts.ResultsWe recruited 33 healthcare providers from an adult oncology setting and 15 healthcare providers from seven additional oncology and fertility settings. At the adult oncology setting, the intervention was found to be appropriate, acceptable, and feasible and improved the screening of fertility needs (from 30% pre- to 51% post-intervention), yet some patients did not receive appropriate referrals to fertility consults. Providers across all settings suggested content and context modifications, such as adding options to the intervention or allowing the screening component to pop up at a second visit, to improve and adapt the intervention to better fit their clinical care contexts.ConclusionsWe found that the EHR-enabled intervention increased the rate of goal-concordant oncofertility care delivery at an adult oncology program. We also identified facilitators, barriers, and needed adaptations to the intervention required for implementation and scaling up across diverse oncology settings.

Background In 2016, the California Department of Healthcare Services (DHCS) released an “All Plan Letter” (APL 16-014) to its Medicaid managed care plans (MCPs) providing guidance on implementing tobacco-cessation coverage among Medicaid beneficiaries. However, implementation remains poor. We apply the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to identify barriers and facilitators to fidelity to APL 16-014 across California Medicaid MCPs. Methods We assessed fidelity through semi-structured interviews with MCP health educators ( N = 24). Interviews were recorded, transcribed, and reviewed to develop initial themes regarding barriers and facilitators to implementation. Initial thematic summaries were discussed and mapped onto EPIS constructs. Results The APL (Innovation) was described as lacking clarity and specificity in its guidelines, hindering implementation. Related to the Inner Context, MCPs described the APL as beyond the scope of their resources, pointing to their own lack of educational materials, human resources, and poor technological infrastructure as implementation barriers. In the Outer Context, MCPs identified a lack of incentives for providers and beneficiaries to offer and participate in tobacco-cessation programs, respectively. A lack of communication, educational materials, and training resources between the state and MCPs (missing Bridging Factors) were barriers to preventing MCPs from identifying smoking rates or gauging success of tobacco-cessation efforts. Facilitators included several MCPs collaborating with each other and using external resources to promote tobacco cessation. Additionally, a few MCPs used fidelity monitoring staff as Bridging Factors to facilitate provider training, track providers’ identification of smokers, and follow-up with beneficiaries participating in tobacco-cessation programs. Conclusions The release of the evidence-based APL 16-014 by California's DHCS was an important step forward in promoting tobacco-cessation services for Medicaid MCP beneficiaries. Improved communication on implementation in different environments and improved Bridging Factors such as incentives for providers and patients are needed to fully realize policy goals. Plan Language Summary In 2016, the California Department of Healthcare Services (DHCS) in California released an “All Plan Letter” (APL 16-014) to its Medicaid managed care plans (MCPs) providing guidance on implementing tobacco-cessation coverage to address tobacco use among Medicaid beneficiaries. We conducted semi-structured interviews with health educators in California Medicaid MCPs to explore the barriers and facilitators to implementing the APL using the Exploration, Preparation, Implementation, Sustainment framework. According to MCPs, barriers included a lack of clarity in the APL guidelines; a lack of resources, including educational materials, infrastructure to identify smokers, and human resources; and a lack of incentives or penalties for providers to provide tobacco-cessation materials to beneficiaries. Facilitators included collaboration between MCPs and state and/or national public health programs. Overall, our findings can provide avenues for improving the implementation of tobacco-cessation services within Medicaid MCPs.

There is increasing evidence supporting the effectiveness of psychological interventions in low- and middle-income countries. However, primary care providers (PCPs) may prefer treating patients with medication. A secondary exploratory analysis of a pilot cluster randomized controlled trial was conducted to evaluate psychological vs. pharmacological treatment preferences among PCPs. Thirty-four health facilities, including 205 PCPs, participated in the study, with PCPs in 17 facilities assigned to a standard version of the mental health Gap Action Programme (mhGAP) training delivered by mental health specialists. PCPs in the other 17 facilities received mhGAP instruction delivered by specialists and people with lived experience of mental illness (PWLE), using a training strategy entitled Reducing Stigma among HealthcAre ProvidErs (RESHAPE). Pre- and post- intervention attitudes were measured through quantitative and qualitative tools. Qualitative interviews with 49 participants revealed that PCPs in both arms endorsed counseling’s benefits and collaboration within the health system to provide counseling. In the RESHAPE arm, PCPs were more likely to increase endorsement of statements such as “depression improves without medication” (F = 9.83, p < 0.001), “not all people with depression must be treated with antidepressants” (χ2 = 17.62, p < 0.001), and “providing counseling to people who have alcohol abuse problems is effective” (χ2 = 26.20, p < 0.001). These mixed-method secondary findings from a pilot trial suggest that in-person participation of PWLE in training PCPs may not only reduce stigma but also increase PCPs’ support of psychological interventions. This requires further investigation in a full-scale trial.

Background Thalassemia is a common inherited hemoglobin disorder in Southeast Asia. Severe thalassemia can lead to significant morbidity for patients and economic strain for under-resourced health systems. Thailand’s thalassemia prevention and control program has successfully utilized prenatal screening and diagnosis to reduce the incidence of severe thalassemia in Thai populations, but migrant populations are excluded despite having high thalassemia prevalence. We sought to identify key barriers to and facilitators of thalassemia screening and to develop tailored recommendations for providing migrants with access to thalassemia prevention and control. Methods We conducted 28 in-depth interviews and 4 focus group discussions (FGDs) in Chonburi, Thailand with Myanmar and Cambodian migrants, Thai healthcare providers, Thai parents of children affected by thalassemia, and migrant agents. Results Participant narratives revealed that migrants’ lack of knowledge about the prevalence, manifestations, severity, and inherited nature of thalassemia led to misconceptions, fear, or indifference toward thalassemia and screening. Negative perceptions of pregnancy termination were based in religious beliefs but compounded by other sociocultural factors, presenting a key obstacle to migrant uptake of prenatal screening. Additionally, structural barriers included legal status, competing work demands, lack of health insurance, and language barriers. Participants recommended delivering public thalassemia education in migrants’ native languages, implementing carrier screening, and offering thalassemia screening in convenient settings. Conclusions An effective thalassemia prevention and control program should offer migrants targeted thalassemia education and outreach, universal coverage for thalassemia screening and prenatal care, and options for carrier screening, providing a comprehensive strategy for reducing the incidence of severe thalassemia in Thailand and establishing an inclusive model for regional thalassemia prevention and control.

Purpose: Oncofertility care at cancer diagnosis remains underimplemented across oncology and fertility care settings, with limited tools to scale up effective implementation strategies. Using implementation science theory, we systematically assessed factors that influence oncofertility care implementation and mapped scalable strategies, particularly electronic health record (EHR)-enabled ones, that fit adult and pediatric oncology care contexts. Methods: Using purposeful sampling, we recruited health care providers and female, reproductive-aged survivors of adolescent and young adult (AYA) cancers (AYA survivors) from a comprehensive cancer center and a freestanding children's hospital to semistructured interviews and focus groups. Using thematic analysis combining inductive codes with deductive codes using the Consolidated Framework for Implementation Research (CFIR), we characterized barriers and facilitators to care and designed responsive strategies. Two coders independently coded each transcript. Results: We recruited 19 oncology and fertility providers and 9 cancer survivors. We identified barriers and facilitators to oncofertility care in the CFIR domains of individual, inner setting, outer setting, and process, allowing us to conceptualize oncofertility care to encompass three core components (screening, referral, and fertility preservation counseling) and map five strategies to these components that fit an adult and a children's context and bridge oncology and fertility practices. The strategies were screening using a best practice advisory, referral order, telehealth fertility counseling, provider audit and feedback, and provider education. All but provider education were EHR tools with embedded efficiencies. Conclusions: An implementation science approach systematically assessed oncofertility care and mapped strategies to provide a theory-based approach and scalable EHR tools to support wider dissemination.

To increase cultural relevance and maximize access for historically underserved populations, there is a need to explore mechanisms underlying treatment outcomes during piloting. We developed a mixed-method approach, Integrated Clinical and Implementation Mapping (ICIM), to explore clinical and implementation mechanisms to inform improvements in content and delivery. We applied ICIM in a pilot of Tuko Pamoja, a lay counselor-delivered family intervention in Kenya (10 families with adolescents ages 12-17). ICIM is a 3-phase process to triangulate data sources to analyze how and why change occurs within individual cases and across cases. We synthesized data from session and supervision transcripts, fidelity and clinical skills ratings, surveys, and interviews. Outputs included a comprehensive narrative and visual map depicting how content and implementation factors influenced change. For Tuko Pamoja, ICIM results showed common presenting problems, including financial strain and caregivers' distress, triggering negative interactions and adolescent distress. ICIM demonstrated that active treatment ingredients included communication skills and facilitated, prescribed time together. Families improved communication, empathy, and hope, facilitated improved family functioning and mental health. Key implementation mechanisms included provider clinical competencies, alliance-building, treatment-aligned adaptations, and consistent attendance. Results guided manual and training refinements and generated hypotheses about mechanisms to test in larger trials.

The Laser interstitial thermal therapy (LITT) technique has been used recently for corpus callosotomy in patients with epilepsy, especially atonic seizures (drop attacks) and Lennox-Gastaut Syndrome (LGS). However, there is little data on safety and outcomes. Therefore, the authors systematically studied and conducted a pooled analysis with special focus on feasibility, outcomes and complications.A systematic review was performed in accordance with the PRISMA guidelines. A total of 10 retrospective studies were identified, comprising 58 cases of MRI-guided LITT treatment.MRI-guided LITT was successfully performed in 57 cases while one case was aborted due to hemorrhage. The average duration of clinical follow-up following LITT callosotomy was 20 months. In the 57 LITT callosotomies, complete seizure freedom and excellent seizure control (Engel I and II) were achieved in 21.1% and 49.1% of patients, respectively. For atonic seizures, the rate of complete freedom and excellent control was 52.5% and 72.5%, respectively. The median length of stay at hospital was 2 days. No death was encountered. Common complications included: fiber-related hemorrhage (8.6%), inaccurate placement (6.9%) followed with transient hemiparesis/hemineglect and supplementary motor area (SMA) syndrome 5.2% each. The rate of disconnection syndrome was 3.4%.MRI-guided LITT for corpus callosotomy is feasible and safe, with low complication rates, short hospitalization and has comparable rates of seizure control to that of classic surgical callosotomy. The majority of patients with atonic seizures achieve complete seizure freedom and excellent control (Engel I and II). The risk for developing disconnection syndrome is low.

ObjectiveTo describe the design and implementation of state-level fertility preservation (FP) health insurance benefit mandates and regulation and to provide stakeholders with guidance on best practices, gaps, and implementation needs.DesignLegal mapping and implementation framework-guided analysisSettingU.S. states with state-level fertility preservation health insurance benefit mandatesPatient(s)Individuals at risk of iatrogenic infertilityIntervention(s)State laws mandating health insurance benefit coverage for fertility preservation services.Main Outcome Measure(s)Design features of FP mandated benefit legislation; implementation processResult(s)Between June, 2017 and March, 2021, 11 states passed FP benefit mandate laws. On average, states took 223 days to implement their mandates from the start of the laws’ enactment dates to their corresponding effective dates, and a majority issued regulatory guidance after the law was in effect. Significant variation was observed in which FP services were specified for inclusion or exclusion in the laws and/or regulator guidance. Federal policies impacted state level implementation, with the ACA and HIPAA guiding design of fertility preservation benefits. In addition, a majority of states referenced medical society clinical practice guidelines in the design of FP mandated benefits.ConclusionsOur policy scan documented significant variation in the design and implementation of health insurance benefit mandates for FP services. Future considerations for policy development include specificity and flexibility of benefit design, reference to external clinical practice guidelines to drive benefit coverage, inclusion of Medicaid populations in required coverage, and consideration of interaction with relevant state and federal policies. In addition, key considerations for implementation include the sufficient length of time for the implementation period, regulator guidance issued prior to the law going into effect, and explicit allocation of resources for the implementation process.